Development of Pre-Anesthesia Documentation in Electronic Medical Record Anesthesia (AREME)
DOI:
https://doi.org/10.56127/jukim.v5i02.2615Keywords:
Anesthesia Nursing Care, Development, Documentation, Electronic Medical RecordAbstract
Anesthesia Care Nursing Documentation (ASKAN) is a record that contains the actions performed by an anesthesiologist on a patient. In the existing Electronic Medical Record Anesthesia (AREME) application, documentation is limited to intra-anesthesia. This does not align with the guidelines in the Anesthesia Care Nursing Documentation (ASKAN) manual. This study aims to develop the AREME application by adding pre-anesthesia documentation, in accordance with the guidelines outlined in the ASKAN manual. The research method used is Research and Development (R&D) with the Waterfall software development method, which includes the stages of Requirement, Design, Implementation, Verification, and Maintenance. The results of this study produced a new interface and pre-anesthesia documentation in the AREME application, in accordance with the guidelines in the ASKAN manual. System testing was conducted using Black Box Testing with Use Case testing techniques, and the results showed that all system functions operate according to the specified requirements. Therefore, this study successfully developed pre-anesthesia documentation in the web-based Electronic Medical Record Anesthesia (AREME) application.
References
[1]I. K. Setiabudi et al., Asuhan Keperawatan Anestesiologi/Asuhan Kepenataan Anestesi (ASKAN). Purwokerto, Indonesia, 2023. [Online]. Available: http://eprints.uhb.ac.id/id/eprint/2324
[2]O. B. Omole, M. Torlutter, A. J. Akii, S. Africa, and O. Omole, “Preanaesthetic assessment and management in the context of the district hospital,” 2021, pp. 1–7, doi: 10.4102/safp.v63i1.5357.
[3]Y. B. Woldegerima and S. D. Kemal, “Clinical audit on the practice of documentation at preanesthetic evaluation in a specialized university hospital,” 2018, pp. 819–824, doi: 10.4103/aer.AER.
[4]A. Mumtaz, R. Zahid, R. Sherazi, N. Aslam, K. Shakoor, and W. B. Waris, “Improving preoperative care in Pakistan: An evaluation of pre-anesthetic record completeness and documentation practices,” vol. 17, no. 2, 2025, doi: 10.7759/cureus.79761.
[5]B. W. Abadi, M. Tania, G. Ching, T. Hardiyani, and R. Annisa, “Pengembangan anestesi rekam medis elektronik (AREME) untuk dokumentasi asuhan keperawatan anestesiologi,” vol. 6, no. 2, pp. 126–136, 2025, doi: 10.25047/j-remi.v6i2.5715.
[6]F. Wurster et al., “Differences in changes of data completeness after the implementation of an electronic medical record in three surgical departments of a German hospital: A longitudinal comparative document analysis,” BMC Medical Informatics and Decision Making, vol. 24, no. 1, 2024, doi: 10.1186/s12911-024-02667-0.
[7]D. W. Sutha, L. Masyfufah, E. W. Faida, and T. Wahyuni, “The impact of use of electronic medical records on the quality of health services and patient safety: Review,” vol. 3, no. 1, pp. 1–11, 2025.
[8]D. Puteri, A. Pramesti, D. Ayuningtyas, and R. Verdi, “Keamanan dan kerahasiaan data medis pasien dalam implementasi rekam medis elektronik,” vol. 8, pp. 7691–7702, 2024.
[9]Y. W. Putri et al., “Implementasi dan dampak penggunaan sistem rekam medis elektronik (RME) pada pelayanan kesehatan,” vol. 3, no. 4, pp. 255–264, 2024, doi: 10.54259/sehatrakyat.v3i4.3449.
[10]M. G. Taye, E. Fenta, T. Tamire, and Y. Fentie, “Assessment of perioperative anesthesia record sheet completeness: A multi-center observational study,” Annals of Medicine and Surgery, vol. 79, p. 104103, 2022, doi: 10.1016/j.amsu.2022.104103.
[11]S. S. Maroufi, B. S. Zilan, P. Moradimajd, and J. Abolghasemi, “The importance of pre-anesthetic evaluation in patient safety: A systematic review,” Archives of Anesthesiology and Critical Care, vol. 10, no. Autumn, pp. 622–630, 2024, doi: 10.18502/aacc.v10is2.17225.
[12]L. Judijanto, M. Muhammadiah, R. N. Utami, and L. Suhirman, Metodologi Research and Development (Teori dan Penerapan Metodologi RnD). Jambi, Indonesia: PT Sonpedia Publishing Indonesia, 2024.
[13]U. Achlison, J. T. Santoso, K. Rozikin, and F. Diapoldo, “Analisis model implementasi tracking pengiriman barang menggunakan Waterfall dan Rapid Application Development,” vol. 5, pp. 90–97, 2025.
[14]N. Hidayati, A. Priandi, Y. Sembiring, D. Sirait, and I. Fachry, “Sistem informasi di Apotek Whitney menggunakan metode Waterfall,” vol. 7, no. 1, pp. 50–60, 2025.
[15]A. A. Wahid, “Analisis metode Waterfall untuk pengembangan sistem informasi,” pp. 1–5, 2020.
[16]Y. D. Cahyono, L. W. Widianti, S. I. Pramuningsih, P. A. Darat, and A. W. Development, “Pengujian black box pada website sistem informasi pengolahan data teritorial menggunakan metode use case testing untuk operasi militer,” vol. 9, no. 2, pp. 2250–2256, 2025.
[17]B. Alturas, “Connection between UML use case diagrams and UML class diagrams: A matrix proposal,” vol. 72, no. 3, 2023.
[18]S. W. Ramdany, S. A. Kaidar, B. Aguchino, C. Amelia, and A. Putri, “Penerapan UML class diagram dalam perancangan sistem informasi perpustakaan berbasis web,” vol. 5, no. 1, 2024.
[19]G. F. Fitriana, “Pengujian aplikasi pengenalan tulisan tangan menggunakan model behaviour use case,” vol. 7, no. 2, 2020.
[20]M. C. Wibowo, T. Wijanarko, and A. Putra, “Utilizing phpMyAdmin for system design in enterprise administration,” vol. 3, no. 2, pp. 217–234, 2024, doi: 10.51903/jtie.v3i2.193.
[21]I. Šušter and T. Ranisavljević, “Optimization of MySQL database,” vol. 11, no. 1, pp. 141–151, 2023.
[22]P. K. Ayuningtyas and P. Rachmadi, “Performance and functional testing with the black box testing method,” vol. 39, no. 2, pp. 212–218, 2023.













