Analysis of the Digitalization of Inpatient Informed Consent Forms in Supporting the Implementation of Electronic Medical Records at the West Java Provincial Occupational Health Regional Hospital

Vollständiger Abstract

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Digital transformation in the healthcare sector is part of the national strategic agenda to improve healthcare quality, operational efficiency, and data integrity. This study aimed to analyze the digitalization of inpatient informed consent forms in supporting the implementation of electronic medical records (EMRs). A descriptive quantitative design was employed, involving a sample of 234 medical record files selected using purposive sampling. Data were collected through observation, document review, and interviews. The findings showed that, among the 234 files examined, 221 (94.4%) manual informed consent forms were complete, whereas only 48 (20.5%) were available in the EMR system. Of the complete forms, only 45 (20.4%) had been uploaded to the EMR, while 176 (79.6%) had not been uploaded. Among the 13 incomplete forms, 3 had nevertheless been digitalized and uploaded to the EMR. These findings indicate the need to improve the digitalization of informed consent forms by optimizing scanning and uploading processes, establishing relevant policies and standard operating procedures (SOPs), strengthening healthcare professional compliance, and developing electronic signature implementation that is directly integrated into the EMR system.