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All Journal Jurnal An-Najat: Jurnal Ilmu Farmasi dan Kesehatan
Sheftyzuani Minur
Politeknik Piksi Ganesha
Dentistry Health Professions Nursing Public Health Veterinary

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ANALISIS KEPATUHAN PENGISIAN REKAM MEDIS ELEKTRONIK PADA FORMULIR INFORMED CONSENT PASIEN OPERASI DI RUMAH SAKIT AZRA Sheftyzuani Minur; Irda Sari
An-Najat Vol. 4 No. 2 (2026): Mei : An-Najat: Jurnal Ilmu Farmasi dan Kesehatan
Publisher : STIKes Ibnu Sina Ajibarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59841/an-najat.v4i2.4004

Abstract

Completion of surgical informed consent forms is an important component of the Electronic Medical Record (EMR) because it relates to administrative aspects, quality of care, and legal protection. However, incomplete entries in several components of the surgical informed consent form were still found at Azra Hospital. This study aimed to determine the compliance rate of surgical informed consent form completion in the EMR at Azra Hospital for the period January – March 2026 based on the completeness of each form component. A descriptive quantitative method with total sampling was used, including 131 surgical informed consent forms. Data were obtained from form recapitulation in Microsoft Excel and the Teramedik application. The results showed that the compliance rate for completing surgical informed consent forms was categorized as good. The component with the highest completeness rate was the patient’s signature at 97,71%, while the lowest completeness rate was found in the family witness name at 78,63%. The study concluded that compliance in completing surgical informed consent forms at Azra Hospital is generally good, but improvement is needed for certain components, particularly the name and signature of the family witness, so that all forms are fully completed according to regulations.
Co-Authors Irda Sari