Efektivitas penggunaan asuhan keperawatan digital terhadap kualitas dokumentasi keperawatan: A systematic review - Firmansyah, Dedy; Kamaluddin, Ridlwan; Purnawan, Iwan (Program Studi Ilmu Keperawatan-fakultas Ilmu Kesehatan Universitas Malahayati, 2025)
Background: Nursing care documentation plays an important role in improving the quality of care, ensuring the accuracy of patient data, and supporting clinical decision making. However, manual documentation methods often face challenges such as time constraints, high workload, and the risk of data loss. Digitization of nursing documentation is expected to overcome these obstacles by increasing efficiency, accuracy, and data security. Purpose: To evaluate the effectiveness of the use of digital nursing care on the quality of nursing documentation. Method: A systematic review study following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Data sources were obtained from databases including; PubMed, Scopus, Google Scholar, and Science Direct with a publication period of 2019–2024. The keywords used were the effectiveness of digital nursing documentation, electronic medical records, and its impact on service quality. Results: The use of a digital documentation system can increase recording accuracy by up to 40%, save documentation time by up to 30%, and reduce the risk of losing patient data. In addition, this system also allows real-time access to information, thereby improving coordination between health workers. Conclusion: Digitization of nursing documentation has proven effective in improving the efficiency, accuracy, and security of patient data. However, its implementation still faces challenges, such as resistance from nursing staff, limited infrastructure, and the need for ongoing training. Therefore, a comprehensive implementation strategy is needed to ensure that the benefits of this system can be optimized. Keywords: Documentation; Digitization; Electronic Medical Records; Health Information System; Nursing Care. Pendahuluan: Dokumentasi asuhan keperawatan berperan penting dalam meningkatkan kualitas pelayanan, memastikan akurasi data pasien, dan mendukung pengambilan keputusan klinis. Namun, metode dokumentasi manual sering kali menghadapi tantangan, seperti keterbatasan waktu, beban kerja tinggi, dan risiko kehilangan data. Digitalisasi dokumentasi keperawatan diharapkan dapat mengatasi kendala tersebut dengan meningkatkan efisiensi, akurasi, dan keamanan data. Tujuan: Untuk mengevaluasi efektivitas penggunaan asuhan keperawatan digital terhadap kualitas dokumentasi keperawatan. Metode: Penelitian systematic review yang mengikuti protokol Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Sumber data diperoleh dari database meliputi; PubMed, Scopus, Google Scholar, dan Science Direct dengan rentang waktu publikasi 2019–2024. Kata kunci yang digunakan yakni efektivitas dokumentasi keperawatan digital, rekam medis elektronik, dan dampaknya terhadap kualitas layanan. Hasil: Penggunaan sistem dokumentasi digital dapat meningkatkan akurasi pencatatan hingga 40%, menghemat waktu dokumentasi sebesar 30%, dan mengurangi risiko kehilangan data pasien. Selain itu, sistem ini juga memungkinkan akses informasi secara real-time, sehingga meningkatkan koordinasi antar tenaga kesehatan. Simpulan: Digitalisasi dokumentasi keperawatan terbukti efektif dalam meningkatkan efisiensi, akurasi, dan keamanan data pasien. Namun, implementasinya masih menghadapi tantangan, seperti resistensi tenaga keperawatan, keterbatasan infrastruktur, dan kebutuhan pelatihan berkelanjutan. Oleh karena itu, diperlukan strategi implementasi yang komprehensif untuk memastikan manfaat sistem ini dapat dioptimalkan. Kata Kunci: Asuhan Keperawatan; Digitalisasi; Dokumentasi; Rekam Medis Elektronik; Sistem Informasi Kesehatan.