Abstrak
Latar belakang: Perkembangan teknologi informasi di bidang kesehatan, salah satunya adalah rekam medik elektronik. Penelitian sebelumnya mengatakan bahwa rekam medik fisik lebih lengkap di bandingkan dengan rekam medik elektronik (92,4 % vs 72,6 % dengan p < 0,001) dan pengisian cepat (2-6 menit) di bandingkan rekam medik elektronik (5-9 menit). Hal tersebut perlu di analisa terutama di critical unit, seperti Intensive Care Unit (ICU) yang monitoring, evaluasi dan pencatatan di lakukan secara berkala dan berkesinambungan. Subyek dan metode: Metode penelitian deskriptif dan kualitatif dengan pendekatan cross sectional. Analisis deskriptif di lakukan terhadap 40 rekam medik pasien rawat inap di ICU RS Yarsi tahun 2019. Analisis kualitatif dilakukan dengan wawancara mendalam. Hasil: di dapatkan hasil kelengkapan pengisian monitoring 71.87 %, keakuratan 62.5 %, ketepatan waktu 87.5 % dan sesuai hukum 85 %. Kesimpulan: Efektivitas rekam medik elektronik di ICU belum sesuai dengan indikator mutu 100 %
Backgrounds: The development of information technology in the health care, one of which is electronic medical record. Previous research said that the physical record is more complete compared to electronic medical records (92.4% vs 72.6% with < 0.001). It needs to be analyzed especially in critical units, such as Intensive Care Unit (ICU) which monitoring, evaluation and recording is done periodically and continuously every hour. Subject and Methods: This research used descriptive and quantitative methods with a cross sectional approach. Descriptive data gotten from medical records with total 40 inpatients in Intensive Care Yarsi Hospital used. While qualitative data was gotten from in depth interviews. Results: result of filling monitoring in EMR 71.87%, accuracy 62.5%, timeliness 87.5% and according to the law 85%. Conclusions: The effectiveness of electronic medical record in ICU has not been in accordance with 100% quality indicator