ANALYSIS OF DIGITALIZED ICU PATIENT INITIAL ASSESSMENT FORMS TO SUPPORT ELECTRONIC MEDICAL RECORDS

Abstract

Digitizing initial assessments is an effort to support electronic medical records. One private hospital in Palembang has been using an electronic medical record system since 2024. However, in its implementation, several forms are still manually filled out. The purpose of this study was to determine the process of digitizing initial assessment forms and the factors that cause the informed consent form to still be filled out manually. The study was conducted using a descriptive qualitative method using data collection through interview and observation techniques. For ICU patients, the initial assessment form is created when the patient enters the ICU room. The initial assessment needs to be digitized because the nurse who performs the initial assessment still uses a wet signature when filling in the initial assessment, so it needs to be scanned and uploaded to the SIMRS. From the data of 20 ICU patient medical record numbers viewed from SIMRS between July and December 2024, the results showed that the three types of initial assessment forms had been successfully digitized but not optimally. The checklist sheet that was created showed that for one patient's medical record number, the initial assessment form was still not digitized. This happened because when the scanning process was carried out, the informed consent form was not found in the medical record file folder taken from the ICU room.