Support Email Address

About the Journal

Download [This article belongs to Volume - 63, Issue - 04]

Abstract : Documentation of paper-based nursing care has problems with incompleteness in filling out the initial assessment of hospitalization ≥ 24 hours. Discrepancies between the data from the assessment results with the appointment of nursing problems. The discrepancy between intervention and implementation. The results of interviews with nurses in the service unit showed that incomplete documentation was caused by the large number of documents that had to be filled out, filling in the same data on several forms, and forgetting to fill them out because the room was busy. The workload of nurses is in the medium category. Overcoming the documentation problem was taken by developing an integrated information system using electronic medical records. This study explores technology acceptance (Technology Acceptance Model) from the largest users, namely nursing staff, from perceived ease of usefulness, perceived ease of use, and Computer self-efficacy in using electronic documentation. This study used a qualitative methodology, explorative phenomenology type with action research design through FGD with 12 participants selected by purposive sampling technique. The results obtained from the research resulted in 5 themes, namely Understanding the Electronic Nursing Care Documentation System and Implementation of 3S standards in RME. Confidence in computing abilities in nursing care documentation. Use of technology in nursing. Ease of use of electronic documentation. The design of the Technology Implementation Model in nursing care documentation is expected to be an instrument for evaluating the acceptance of electronic medical record technology at the Elizabeth Hospital in Semarang, so that patient safety and security are guaranteed.