ANALISIS KELENGKAPAN PENGISIAN FORMULIR INFORMED CONSENT RAWAT INAP PADA APLIKASI EMR GUNA MENUNJANG ASPEK HUKUM DI RSUD AL-IHSAN

Abstract

Hospitals have an obligation to ensure that every medical procedure is carried out based on the patient’s valid consent, as evidenced by complete informed consent. This document is important as administrative evidence as well as legal protection in the event of a dispute. This study aims to assess the completeness of filling out inpatient informed consent on the EMR application at Al-Ihsan Hospital. The method used is qualitative with a descriptive approach through observation, in-depth interviews, and document review, analyzed using the Miles and Huberman model. The results of the study on 99 documents showed that 63 % were not filled incomplete, especially in the substantive part ( diagnosis, indications, risks ), while the admininstrative part ( patient, doctor, witness’s signature ) was mostly filled. Supporting factors for completeness include socialization, training, management commitment, and availability of facilities. The main obstacles are the limitations of officer adaptation to EMR and system validation features that are not optimal. Improvements can be mad through increased training, updating SOPs according to the latest regulations, and strengthening validation features to support the completeness of informed consent as legal protection for patients and hospitals.