Evaluation of Electronic Medical Record Implementation and the Quality of Medical Record Documentation in Hospitals in South Sumatra
DOI:
https://doi.org/10.70963/jm.v2i4.712Keywords:
Electronic Medical Records, Medical Record Quality, Implementation, HospitalAbstract
Electronic medical records (EMR) are part of the digital transformation in the healthcare sector aimed at improving service quality through more efficient and accurate patient data management. This study aimed to evaluate the implementation of electronic medical records and the quality of medical record documentation in a hospital in South Sumatra. This study employed a quantitative approach with a descriptive analytic design. The sample consisted of 100 inpatient medical record documents selected using purposive sampling. Data were collected through observation using a checklist and analyzed using univariate and bivariate analysis with the Chi-Square test. The results showed that the completeness of medical record documentation was 80%, with patient identity having the highest completeness (90%) and physician signatures the lowest (70%). The implementation of EMR was optimal in 60% of cases, while 40% were not optimal. Statistical analysis revealed a significant relationship between EMR implementation and the quality of medical record documentation (p = 0.003). The implementation of electronic medical records contributes to improving the quality of medical record documentation; however, further optimization is needed through improving healthcare personnel competence, strengthening system infrastructure, and conducting regular evaluations.
Downloads
References
Belrado, M., Suryani, L., & Pratama, A. (2024). Implementasi rekam medis elektronik dan tantangan integrasi sistem di rumah sakit. Jurnal Keperawatan dan Pelayanan Kesehatan, 7(2), 112–120.
Izza, N., & Lailiyah, S. (2024). Analisis hambatan implementasi rekam medis elektronik di rumah sakit Indonesia. Media Gizi dan Kesehatan, 13(1), 45–53.
Mulyana, D., Rahmawati, E., & Hidayat, T. (2023). Analisis kelengkapan pengisian rekam medis rawat inap di rumah sakit. Jurnal Riset Kesehatan, 12(3), 210–218.
Syafanny, R., Putra, A., & Lestari, D. (2024). Evaluasi penerapan rekam medis elektronik dalam meningkatkan kualitas pelayanan kesehatan. Jurnal Manajemen Informasi Kesehatan Indonesia, 12(1), 25–33.
Zuhdi, M., & Darmawan, R. (2024). Faktor yang mempengaruhi kualitas rekam medis dalam pelayanan kesehatan. Jurnal Inovasi Kesehatan, 5(2), 98–106.
Putri, A., Handayani, S., & Prakoso, B. (2023). Hubungan kelengkapan rekam medis dengan mutu pelayanan kesehatan di rumah sakit. Jurnal Kesehatan Masyarakat, 11(2), 134–142.
Rahmawati, N., & Saputra, D. (2022). Pengaruh implementasi rekam medis elektronik terhadap efisiensi pelayanan kesehatan. Jurnal Administrasi Kesehatan, 10(1), 55–63.
Hidayat, T., & Kurniawan, A. (2023). Evaluasi kualitas pengisian rekam medis pada pasien rawat inap. Jurnal Ilmiah Rekam Medis dan Informasi Kesehatan, 8(2), 89–97.
Sari, D., & Nugroho, R. (2021). Penerapan sistem informasi kesehatan dalam meningkatkan mutu pelayanan rumah sakit. Jurnal Sistem Informasi Kesehatan, 6(1), 21–30.
Wulandari, F., & Putra, H. (2022). Analisis kepatuhan tenaga kesehatan dalam pengisian rekam medis. Jurnal Kesehatan Indonesia, 9(3), 145–152.
Prasetyo, E., & Lestari, Y. (2021). Faktor-faktor yang mempengaruhi implementasi rekam medis elektronik di rumah sakit. Jurnal Manajemen Kesehatan, 7(1), 33–41.
Utami, R., & Dewi, S. (2022). Evaluasi sistem rekam medis elektronik dalam meningkatkan kualitas pelayanan pasien. Jurnal Teknologi Kesehatan, 5(2), 77–85.
Downloads
Published
How to Cite
License
Copyright (c) 2026 Novta Santoso, Reza Futriana , Nada Ledika , Zakiatul Hasanah , Khairunnisa Khairunnisa , Fitriah Fitriah
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
