OPTIMALISASI FORMULIR CHECKLIST PRE OPERASI, ASSESSMENT NYERI, DAN ASSESSMENT RISIKO JATUH DALAM REKAM MEDIS ELEKTRONIK (RME) DI RUANG MARWA RSI ARAFAH JAMBI

Yunida Ihsani, Syifa (2025) OPTIMALISASI FORMULIR CHECKLIST PRE OPERASI, ASSESSMENT NYERI, DAN ASSESSMENT RISIKO JATUH DALAM REKAM MEDIS ELEKTRONIK (RME) DI RUANG MARWA RSI ARAFAH JAMBI. S1 thesis, Universitas Jambi.

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Abstract

ABSTRACK The use of electronic medical record (RME) systems is an important strategy in improving the efficiency, accuracy, and security of nursing documentation in hospitals. At the Arafah Jambi Islamic Hospital, the RME system has been implemented in the Marwa inpatient ward, but there are still several important nursing forms that are not yet available in digital format, such as pre-operative Checklist forms, pain reAssessments, and fall risk reAssessments. This causes duplication of recording, delays in documentation, and potential recording errors that can impact the quality of nursing services and patient safety. This paper aims to design and compile digital drafts of the three forms as an initial step in optimizing the use of the RME system. The methods used include direct observation and interviews with the head of the room and the implementing nurse, followed by the process of compiling a digital draft that does not change the substance of the manual form. The draft is then validated by the head of the room and the head of nursing, then officially submitted to the hospital management to be forwarded to the IT team for the integration process into the RME system. The results of the activity show that the pre paration of the digital draft has been successfully carried out systematically and structured. The draft received positive responses from management and the IT team, with plans to integrate into the RME system in December 2025 after the completion of the outpatient system development. Collaboration between the nursing team and management was an important factor in ensuring the suitability of the content and acceptability of the draft. In conclusion, the pre paration of this digital form is a strategic initial step in supporting the digitization process of nursing documentation at RSI Arafah Jambi. It is hoped that the full implementation of the RME system can improve the efficiency of nurses' work, accelerate access to information, and improve the quality of nursing services in the future. Keywords: Electronic Medical Records, Digital Forms, Nursing Documentation. xv ABSTRAK Penggunaan sistem Rekam Medis Elektronik (RME) merupakan strategi penting dalam meningkatkan efisiensi, akurasi, dan keamanan dokumentasi keperawatan di rumah sakit. Di Rumah Sakit Islam Arafah Jambi, sistem RME telah diterapkan, namun masih terdapat beberapa formulir penting keperawatan yang belum tersedia dalam format digital, seperti formulir Checklist pre operasi, Assessment nyeri, dan Assessment risiko jatuh dikarenakan belum tersedianya format digital sehingga menjadi hambatan tim IT untuk proses integrasi. Penulisan ini bertujuan untuk merancang dan menyusun draft digital dari ketiga formulir tersebut sebagai langkah awal optimalisasi penggunaan sistem RME. Metode yang digunakan meliputi observasi langsung dan wawancara dengan kepala ruangan serta perawat pelaksana, dilanjutkan dengan proses penyusunan draft digital yang tidak mengubah substansi dari formulir manual. Draft kemudian divalidasi oleh kepala ruang dan kepala keperawatan, lalu diajukan secara resmi kepada manajemen rumah sakit untuk diteruskan kepada tim IT guna proses integrasi ke dalam sistem RME. Hasil kegiatan menunjukkan bahwa penyusunan draft digital telah berhasil dilakukan secara sistematis dan terstruktur. Draft mendapat tanggapan positif dari manajemen dan tim IT, dengan rencana integrasi ke dalam sistem RME pada bulan Desember 2025 setelah penyelesaian pengembangan sistem rawat jalan. Kolaborasi antara tim keperawatan dan manajemen menjadi faktor penting dalam memastikan kesesuaian isi dan keberterimaan draft.Kesimpulannya, penyusunan formulir digital ini menjadi langkah awal yang strategis dalam mendukung proses digitalisasi dokumentasi keperawatan di RSI Arafah Jambi. Diharapkan implementasi penuh sistem RME dapat meningkatkan efisiensi kerja perawat, mempercepat akses informasi, dan meningkatkan mutu pelayanan keperawatan di masa mendatang. Kata Kunci: Rekam Medis Elektronik, Formulir Digital, Dokumentasi Keperawata

Type:	Thesis (S1)
Uncontrolled Keywords:	Electronic Medical Records, Digital Forms, Nursing Documentation
Subjects:	L Education > L Education (General)
Divisions:	Fakultas Kedokteran dan Ilmu Kesehatan > Ilmu Keperawatan
Depositing User:	SYIFA YUNIDA IHSANI
Date Deposited:	09 Jul 2025 07:10
Last Modified:	09 Jul 2025 07:10
URI:	https://repository.unja.ac.id/id/eprint/82045

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