Perancangan Rekam Medis Elektronik Untuk Tindakan Operasi Di Rumah Sakit Universitas Ahmad Dahlan

Zahra Nabila Adistya Hariyanto, Dian Budi Santoso, S. KM., M.P.H.

2024 | Tugas Akhir | D4 MANAJEMEN INFORMASI KESEHATAN

Latar Belakang: Melalui Permenkes Nomor 24 Tahun 2022, pemerintah mewajibkan seluruh fasilitas pelayanan kesehatan untuk menyelenggarakan Rekam Medis Elektronik. RS UAD telah menyelenggarakan rekam medis elektronik melalui SIMRS, namun belum meliputi seluruh pelayanan, salah satunya rawat inap. Pemanfaatan rekam medis elektronik dapat mendukung pencatatan rekam medis yang lebih lengkap khususnya pada pencatatan operasi karena kasus bedah merupakan kasus berisiko tinggi sehingga membutuhkan pencatatan data yang lengkap agar tidak terjadi hal menyangkut pengadilan. Oleh karena itu, perlu dilakukan perancangan rekam medis elektronik untuk rawat inap khususnya pada pelayanan tindakan operasi.
Tujuan: Menghasilkan desain antarmuka pada rekam medis elektronik tindakan operasi di RS UAD.
Metode: Penelitian ini menggunakan metode Waterfall dan Research & Development di RS UAD. Penelitian dilaksanakan pada Bulan Agustus-September 2023. Subjek Penelitian ini yaitu Profesional Pemberi Asuhan tindakan operasi dan Perekam Medis. Objek Penelitian ini yaitu formulir rekam medis konvensional pada rawat inap operasi. Pengumpulan data dilakukan dengan metode wawancara, observasi, dan studi dokumentasi.
Hasil: Rancangan RME tindakan operasi didesain berbasis web dengan hak akses dokter spesialis bedah terdiri dari 4 menu utama, yaitu informasi tindakan bedah, pernyataan tindakan bedah, Surgical Safety Checklist-sign out, laporan operasi. Sementara, hak akses perawat bedah terdiri dari 4 menu utama, yaitu checklist persiapan operasi, catatan keperawatan intraoperatif, Surgical Safety Checklist-time out, bahan habis pakai.
Kesimpulan: RME tindakan operasi yang sudah dirancang telah sesuai dengan kebutuhan dan diterima oleh pengguna.

Background: Through regulation of The Indonesian Minister of Health Number 24 of 2022, the government requires all health service facilities to implement Electronic Medical Records. UAD Hospital has organized electronic medical records through SIMRS, but has not yet covered all services, one of which is inpatient care. Utilization of electronic medical records can support a more complete recording of medical records, especially in recording operations because surgical cases are high-risk cases that require complete data recording to avoid matters involving the court. Therefore, it is necessary to design electronic medical records for inpatient care, especially in surgical services.
Objective: Designing an electronic medical record user interface for surgery at UAD Hospital.
Methods: This research used the Waterfall and Research & Development methods. The research was conducted in August - September 2023. The subjects of this study were surgical care practitioners and medical recorders. The object of this research is the conventional medical record form in surgical inpatients. Data collection was carried out using interviews, observation, and documentation studies.
Results: The EMR design for surgical procedures is designed to be web-based with specialist surgeon access rights consisting of 4 main menus, namely surgical procedure information, surgical procedure statement, Surgical Safety Checklistsign out, surgical report. Meanwhile, surgical nurses' access rights consist of 4 main menus, namely surgical preparation checklist, intraoperative nursing notes, Surgical Safety Checklist-time out, consumables.
Conclusion: The EMR for surgery that has been designed is in accordance with the needs and accepted by the user.

Kata Kunci : Rekam Medis Elektronik, Tindakan Operasi, RS UAD, Perancangan