Analisis Dokumentasi Kunjungan Masa Nifas Berdasarkan Data EMR di Puskesmas Nalumsari I

Evita Aurilia Nardina; Ratih Kumala Dewi

doi:10.55606/termometer.v3i3.5390

Authors

Evita Aurilia Nardina Universitas Al-Hikmah Jepara
Ratih Kumala Dewi STIKES Estu Utomo Boyolali

DOI:

https://doi.org/10.55606/termometer.v3i3.5390

Keywords:

EMR, midwifery care, postpartum documentation, postpartum visit, women’s health

Abstract

Postpartum visit documentation is a vital component of midwifery care, serving not only as a clinical record but also as an indicator of service quality. The use of Electronic Medical Records (EMR) in primary healthcare settings is expected to improve the accuracy and completeness of postpartum care documentation. This study aimed to analyze the completeness of postpartum visit documentation based on EMR data at Nalumsari I Public Health Center, Jepara Regency. A descriptive quantitative design with a retrospective approach was used to assess 120 postpartum medical records from 2023. The findings showed that the most consistently documented components were blood pressure (98.3%) and uterine involution (95.8%), while psychological status and health education were less frequently recorded (65% and 58.3%, respectively). The Chi-Square test revealed a significant relationship between the number of postpartum visits and the completeness of documentation (p = 0.001). These results indicate that more frequent visits are associated with more complete and higher-quality documentation. This study implies the need to strengthen health workers' capacity in EMR-based documentation, especially in recording non-clinical aspects such as emotional support and postpartum health education.

Downloads

Download data is not yet available.

References

Damayanti, I. (2023). Evaluasi implementasi rekam medis elektronik pada dokumentasi asuhan kebidanan di fasilitas kesehatan primer. Jurnal Kesehatan Reproduksi, 14(1), 45–52.

Dinas Kesehatan Provinsi Jawa Tengah. (2023). Profil kesehatan provinsi Jawa Tengah tahun 2023. https://anyflip.com/gdslm/vzwu/basic/51-100

Hartatik, S. (2022). Kualitas dokumentasi asuhan nifas oleh bidan di Puskesmas wilayah timur. Jurnal Kebidanan Nusantara, 9(2), 101–110.

Kementerian Kesehatan Republik Indonesia. (2020). Pedoman pelayanan antenatal, persalinan, nifas, dan bayi baru lahir. Kemenkes RI.

Kementerian Kesehatan Republik Indonesia. (2020). Standar pelayanan kebidanan di Puskesmas. Kemenkes RI.

Lestari, P., & Sari, M. (2021). Strategi peningkatan dukungan keluarga dalam perawatan ibu nifas. Jurnal Kesehatan Keluarga, 6(3), 128–134.

Mulyani, R. (2021). Perbandingan kelengkapan data EMR antara Puskesmas perkotaan dan pedesaan. Jurnal Sistem Informasi Kesehatan, 6(1), 20–27.

Nurdini, D., & Ramadhan, A. (2024). Effectiveness of community and digital-based family planning interventions in LMICs: A systematic review 2020–2024. In Reproductive Health Research Forum. https://example.org/systematic-review-kb-lmic-2024

Prasetyo, B., & Utami, S. (2019). Evaluasi pelaksanaan pendampingan ibu nifas berbasis komunitas. Jurnal Kesehatan Masyarakat dan Kebidanan, 10(1), 75–83.

Putri, A. (2023). Pengaruh frekuensi kunjungan masa nifas terhadap pengetahuan ibu tentang tanda bahaya. Jurnal Ilmu Kebidanan, 11(1), 34–40.

Rodian. (2024). Studi implementasi EMR di Klinik Purwokerto dan Purbalingga. In arXiv. https://arxiv.org/abs/2410.12226

Rohmah, L. (2022). Aspek psikologis ibu nifas dan dokumentasinya di EMR. Jurnal Psikologi Kesehatan, 8(2), 56–62.

Saifuddin, A. B. (2020). Buku panduan praktis pelayanan kesehatan maternal dan neonatal. Yayasan Bina Pustaka Sarwono Prawirohardjo.

Santosa, D. (2020). Implementasi EMR di fasilitas kesehatan primer: Peluang dan tantangan. Jurnal Teknologi Kesehatan, 7(1), 12–19.

Santoso, Y., & Wijaya, F. (2024). Optimalisasi peran tenaga kesehatan dan kader dalam pendampingan ibu nifas: Studi kasus Puskesmas. Jurnal Kesehatan Nasional, 14(2), 98–107.

Suryana, E., Lestari, A., & Harto, K. (2022). Teori pemrosesan informasi dan implikasi dalam pembelajaran. Jurnal Ilmiah Mandala Education, 8(3).

Varney, H. (2018). Varney’s midwifery (5th ed.). Jones & Bartlett Learning.

Waryono. (2017). Adoption of electronic medical records in U.S. hospitals. Wikipedia. https://en.wikipedia.org/wiki/Adoption_of_electronic_medical_records_in_U.S._hospitals

Widjaja, T. (2021). Faktor-faktor yang mempengaruhi kebutuhan pendampingan ibu nifas: Sebuah tinjauan literatur. Jurnal Ilmiah Kesehatan, 9(4), 201–210.

World Health Organization. (2018). Recommendations on postnatal care of the mother and newborn. WHO Press.

World Health Organization. (2022). Digital health guidelines for maternal and child health. WHO Press.