EVALUASI PENERAPAN REKAM MEDIS ELEKTRONIK (RME) DALAM DOKUMENTASI ASUHAN KEPERAWATAN DI RSA UGM: MIXED-METHOD STUDY

Mujiono, Prof. Dr. Christantie Effendy, S.Kp.,M.Kes; Khudazi Aulawi, S.Kp., M.Kes., MN.Sc., Ph.D

2026 | Tesis | S2 Magister Keperawatan

Latar belakang: Penerapan Rekam Medis Elektronik (RME) merupakan langkah strategis dalam tranformasi digital pelayanan kesehatan. Evaluasi komprehensif terhadap digital pelayanan kesehatan. Evaluasi komprehensif terhadap implementasi RME, khususnya untuk dokumentasi asuhan keperawatan, diperlukan guna mengidentifikasi kekuatan dan area perbaikan.

Tujuan: Penelitian ini bertujuan untuk mengidentifikasi gambaran aspek manusia, organisasi, teknologi dan net benefit pada penggunaan RME "SISTEMA" dalam dokumentasi asuhan keperawatan di RSA UGM dengan menggunakan pendekatan mixed-methods.

Metode: Penelitian ini menggunakan desain mixed method study. Data kuantitatif dikumpulkan melalui kuesioner HOT-Fit dari 122 perawat di RSA UGM. Data kualitatif diperoleh melalui wawancara mendalam dengan 10 perawat yang dipilih secara purposive sampling. Analisis data kuantitatif menggunakan statistik deskriptif dan uji non-parametrik (Mann-Whitney & Kruskal-Wallis), sedangkan data kualitatif dianalisis secara tematik.

Hasil: Evaluasi HOT-Fit menunjukkan penerapan RME dinilai sangat baik pada sub domain pengguna sistem dan dinilai baik pada sub domain lainnya, dengan skor tertinggi pada domain Manusia (System Use = 4,36–4,49) dan Net benefit (rerata 3,97–4,05). Secara statistik, skor Net benefit lebih tinggi pada perawat berpendidikan Ners (p=0,032) dan perawat primer/Ka tim (p=0,010). Analisis kualitatif menghasilkan lima tema utama: (1) adaptasi penerapan RME, (2) dukungan penggunaan, (3) hambatan dan tantangan (teknis, pengguna, dan organisasi), (4) keunggulan dan ancaman (seperti privasi data), serta (5) harapan pengembangan sistem dan pelatihan.

Kesimpulan: RME "SISTEMA" di RSA UGM telah diterima dengan baik dan memberikan manfaat yang dirasakan, namun untuk optimalisasi diperlukan perbaikan pada aspek tata kelola organisasi (panduan RME, sosialisasi), infrastruktur (jaringan, perangkat), usability sistem, dan penguatan keamanan data

Background: The implementation of Electronic Medical Records (EMR) is a strategic step in the digital transformation of health services. A comprehensive evaluation of EMR implementation, specifically for nursing care documentation, is needed to identify strengths and areas for improvement.

Objective: This study aims to evaluate the implementation of the EMR for nursing care documentation at RSA UGM using the HOT-Fit model and to explore nurses' experiences and perceptions regarding its barriers and facilitators.

Methods: This study used Convergent parallel mixed method design. Quantitative data were collected via the HOT-Fit questionnaire from 122 nurses at RSA UGM. Qualitative data were obtained through in-depth interviews with 10 purposively selected nurses. Quantitative data were analyzed using descriptive statistics and non-parametric tests (Mann-Whitney & Kruskal-Wallis), while qualitative data were analyzed thematically.

Results: The HOT-Fit evaluation showed that EMR implementation was rated well across all domains, with the highest scores in the Human domain (System Use = 4.36–4.49) and Net Benefit (average 3.97–4.05). Statistically, Net Benefit scores were higher among nurses with a professional nursing degree (Ners) (p=0.032) and among primary nurses/team leaders (p=0.010). Qualitative analysis yielded five main themes: (1) adaptation to EMR implementation, (2) support for use, (3) barriers (technical, user-related, and organizational), (4) advantages and threats (e.g., data privacy), and (5) expectations for system development and training.

Conclusion: The "SISTEMA" EMR at RSA UGM is well-accepted and provides perceived benefits. However, for optimization, improvements are needed in organizational governance (EMR Guidelines, socialization), infrastructure (network, devices), system usability, and strengthening data security.

Kata Kunci : Rekam Medis Elektronik, Evaluasi Asuhan Keperawatan, HOT-Fit Model, Mixed-Methods study.