Published date: Feb 10 2023

Journal Title: KnE Medicine

Issue title: 5th Riau International Nursing Conference (RINC)

Pages: 184–190

DOI: 10.18502/kme.v3i1.12712

Vella Yovinna Tobingvellayovito@gmail.comUniversity of Hang Tuah Pekanbaru

Dian Roza AdilaUniversity of Hang Tuah Pekanbaru

Ibnu SuryaPoliteknik Caltex Riau

Erzi HidayatPoliteknik Caltex Riau

The transition to the digital era also occurs in the health sector. This transition requires adaptation and learning starting from school, such as using electronic medical records. This study aimed to determine the experience of nursing students at Hang Tuah University Pekanbaru using the electronic assessment format. This research uses a phenomenological study approach. Participants used the electronic nursing assessment form (ENAF) which is still being develop by the research team. This study used a consecutive sampling technique that involved 33 nursing students who did clinical practice for the basic nursing skills course. Focus group discussion (FGD) was used to collect the data, it was divided into three groups. The data were analyzed using content analysis. There were two main themes with 7 sub-themes. The themes are dimensions of ENAF and future improvement. Mostly, participants agreed to use ENAF because it was considered more efficient and economical. In addition, the data is also safer without the fear of paper damage. The display of documentation results is also clean, and easier to analyze patients’ problems. Based on participants’ experience using ENAF, there are several obstacles such as forgetting to save the results of the assessments and technical problems when using ENAF on mobile phones. All participants agreed with using ENAF because ENAF is more practical and cheaper than using a paper-based assessment form. Nursing students should be prepared with the ability to use electronic health records so they can adapt to the digital era, especially in the documentation system.

Keywords: digital health record, electronic assessment format, nursing assessment

[1] Amin M, Setyonugroho W, Hidayah N. Implementasi rekam medik elektronik: sebuah studi kualitatif. Jurnal Teknik Informatika dan SIstem Informasi. 2022;8(1):430-442. file:///C:/Users/user/Downloads/557-Article%20Text-2012-2-10-20210406.pdf

[2] Andriani, Wulandari, Margianti. Rekam medis elektronik sebagai pendukung manajemen pelayanan pasien di rs universitas gajah mada. Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda. 2022;7(1):96-107. file:///C:/Users/user/Downloads/599- Article%20Text-4115-1-10-20220302.pdf

[3] Atasoy H, Greemwood BN, McCullough JS. The digitization of patient care: A review of the effects of electronic health records on health care quality and utilization. Annu Rev Public Health. 2022;1(40):487-500. https://doi.org/10.1146/annurev-publhealth- 040218-044206

[4] Baumann LA, Baker J, Elshaug AG. The impact of electronic health record systems on clinical documentation times: a systematic review. Health Policy. 2018;122(8):827- 836. https://doi.org/10.1016/j.healthpol.2018.05.014

[5] Dhamar EN, Rahayu MH. Pengalaman perawat dalam menggunakan reka medis elektronik di rumah sakit panti rini yogyakarta. I Care Jurnal Keperawatan STIKes Panti Rapih. 2020;1(2). https://doi.org/10.46668/jurkes.v1i2.94

[6] Dwijosusilo, Sarni. Peranan rekam medis elektronik terhadap sistem informasi manajemen rumah sakit umum haji surabaya. 2018. http://repository.unitomo.ac.id/id/eprint/1713

[7] Herlina, Rusman, Marlina, Suwardoyo. Penerapan sistem informasi berbasis it pengolahan data rekam medis untuk peningkatan pelayanan di rumah sakit. Pekalongan: PT. Nasya Expanding Management; 2022.

[8] Indonesia Minister of Health. (31 August 2022). Peraturan Menteri Kesehatan Republik Indonesia Nomor 24 Tahun 2022 Tentang Rekam Medis. Retrieved from https://yankes.kemkes.go.id/unduhan/fileunduhan_1662611251_882318.pdf

[9] Kamau N. Electronic health documentation and its impact on nurses routine practices. Laurea University of Appiled Science. 2015. https://www.theseus.fi/ bitstream/handle/10024/104801/Nancy%20Kamau%20PDF.pdf

[10] Kowitlakul Y, Chan SWCC, Pulcini J, Wang W. Factors influencing nursing students’ acceptance of elctronic health records for nursing education (EHRNE) software program. Nurse Education Today. 2014. doi: 10.1016/j.nedt.2014.05.01

[11] Medani KT, Ahmed SM, Sami W, Ahmed SM, Mohamed AY, Abdalla SM, Abdelrahman HH. Use of electronic health records among Saudi and non-Saudi health providers-a comparative study at a secondary hospital, Saudi Arabia. J Pak Med Assoc. 2020;70(9):1591-1595. https://doi.org/10.5455/jpma.20307

[12] Rathert C, Porter TH, Mittler JN, Fleif-Plmer M. Seven years after meaningful use: physicians’ and nurses’ experiences with electonic health records. Health Care Management Review. 2017. DOI: 10.1097/HMR.0000000000000168

[13] Wikina S. What caused the brech? an examination of use of information technology and health data breaches. Perspect Health Information Management AHIMA Am Health Information Management Association. 2014;1(11).

[14] Xiao C, Choi E, Sun J. Oppotunities and challanges in developing deep learning models using electronic health records data: a systematic review. Journal of the American Medical Informatics Association. 2018;25(10):1419-1428. https://doi.org/10.1093/jamia/ocy068