AVITA ARUM MAWARNI, NIM. 202302169 (2024) ANALISIS DOKUMENTASI INTERVENSI DAN IMPLEMENTASI KEPERAWATAN PADA REKAM MEDIS ELEKTRONIK (RME) RAWAT INAP DI RSU PERMATA MEDIKA KEBUMEN. Skripsi thesis, UNIVERSITAS MUHAMMADIYAH GOMBONG.

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Abstract

Background: Digital health transformation has brought significant changes to healthcare services, one of which is through electronic medical records (EMR). EMRs offer efficient, effective, and easily accessible solutions that improve the quality of healthcare services. High-quality nursing documentation in EMRs is crcrucial for the smooth process of care and minimizing medical errors. Objective: To analyze the docuentation of nursing interventions and the implementation of care nursing using Electronic Medical records 9EMR) for inpatients at Permata Medika General Hospital, Kebumen. Methods: This research employed a qulitative approach with ethnographic methods. The participants consisted of four individuals: one ward nurse, one head nurse, one assistant quality and nursing care manager. and one nursing manager. The research instrument used was an interview guide, and data were analyzed qualitatively. Results: The study found that the knowledge and implementation of the 3S standard for pain diagnosis and management varied among nursing staff. Nursing Managers and Assistant Quality and Nursing Care Managers had a better understanding of the 3S standard compared to ward Heads and Team Leaders. Although EMRs improved documentation efficiency, some nurses faced difficulties in documentation due to workload and lack of understnading. The Hospital Information Management System (SIMRS) needs improvement to rupport accurate documentation the 3S standard. Conclusion: Knowledge and implementation of teh 3S standard. Improvements in the SIMRS and intensive training are necessary to enhance understanding and application of the 3S standard. Recomnedation: Improve and develop features in the SIMRS to support more user-friendly and accurate documentation according to the 3S standard

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