Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)

Kesiapan Penggunaan Rekam Medis Elektronik Menggunakan Metode Technology Readiness Index (TRI) di Rumah Sakit Islam Surakarta Yarsis

Khumairoh Az-Zahro — 2025-08-31

Indonesian Ministry of Health Regulation Number 24 of 2022 states that all health service facilities was required to implemented Electronic Medical Records no later than December 31 2023. However, the implementation of Electronic Medical Records at the Surakarta Yarsis Islamic Hospital still found unpreparedness in health service facilities both in terms of human resources and software. Measuring readiness to implement a new technology can be done using the Technology Readiness Index (TRI) method. This study aimed to measure readiness to use Electronic Medical Records at RSIS Yarsis. This research was a of descriptive research using a quantitative approach. The research instrument is a closed questionnaire with a Likert scale. The total research population was 293 people, the sample used was 152 people, calculated using the cross sectional formula. Research data was collected by means of interviews and data analysis in research, namely descriptive statistics. The results showed that readiness of Electronic Medical Records using the TRI method obtained a result of 3.28 in the medium technology readiness index category.

Analisis Kesiapan Penerapan Rekam Medis Elektronik dengan Metode DOQ-IT: Narrative Review

Aji Wahyu Putra — 2025-08-31

By digitizing and integrating patient data, the Electronic Medical Records (EMR) initiative aims to increase the effectiveness and caliber of healthcare services. Using the DOQ-IT method, which encompasses a comprehensive evaluation of organizational support, change management, human resource competency, and technology infrastructure, this study seeks to assess Indonesia's preparedness for EMR implementation. This study reviews ten pertinent journals using a narrative review methodology. The analysis's findings indicate that a number of obstacles still stand in the way of Indonesia's EMR implementation preparedness, including inadequate infrastructure in rural regions, inadequate health worker training, reluctance to adapt, and a lack of specialized funding. However, the findings show that health facilities with strong managerial support and ongoing training programs have a better level of readiness. The DOQ-IT method has proven effective in providing a comprehensive picture of organizational readiness, although its implementation requires adaptation to the local context. By overcoming these obstacles through policy development, improving the competency of health workers, and improving infrastructure, comprehensive EMR implementation in Indonesia can be achieved.

Perancangan Sistem Informasi Pendaftaran Pasien Rawat Jalan Berbasis Web Di Puskesmas Pimping

Elicukia Elicukia — 2025-08-31

The registration process is a crucial element in medical record management, ensuring the smooth operation of healthcare services and impacting the quality of services. This study aims to design a web-based patient registration information system to improve the quality of healthcare services and operational efficiency in community health center. This research employs a qualitative method with a descriptive approach, where data is collected through direct observation, interviews with medical record officers, and literature review. The sample consisted of two medical record officers, and the research was conducted at Pimping Community Health Center (Puskesmas Pimping) on December 20, 2024. For system development, a prototype-based system development method was used. The results of the study reveal that community health centers still use a manual paper-based registration system, leading to recording errors and administrative inefficiencies. To address these issues, a web-based information system has been designed to reduce administrative burdens, improve data accuracy, and accelerate the patient registration process. The implementation of this system demonstrates improved operational efficiency, a reduction in registration errors, and ease for staff in managing patient data through an intuitive interface. As a recommendation, this system requires further testing in real-world settings to gather user feedback, enabling continuous improvements to its features to meet field requirements.

Pengaruh Efektivitas Pelayanan Pendaftaran Online Aplikasi Mobile JKN Terhadap Kepuasan Pasien Rawat Jalan di Rumah Sakit Karya Bhakti Pratiwi Bogor

Yuyun Yunengsih — 2025-08-31

Digital transformation in healthcare services is an essential requirement for enhancing efficiency and patient convenience. This study aims to analyze the influence of the effectiveness of online registration services through the Mobile JKN application on patient satisfaction at Karya Bhakti Pratiwi Hospital in Bogor. The research employed a quantitative approach with a causal associative design involving a survey of 100 outpatient respondents and supporting data from interviews obtained from the period of February 10 to May 10, 2025. The findings indicate that service speed and ease of access are the most important aspects for patients. Factors such as digital literacy, internet network quality, user experience with the application, and staff support significantly contribute to service effectiveness. The effectiveness of the service has been proven to have a significant positive impact on patient satisfaction. Nevertheless, several issues were identified in its implementation, such as discrepancies in real-time information displayed by the application, limited patient understanding of features and registration steps, and an application flow that is not fully understood by some users. Therefore, it is recommended that hospitals emphasize strengthening patients' digital capabilities, improving service infrastructure, and providing staff support to ensure the success of a more inclusive, adaptive, and patient-centered digital healthcare transformation.

Tinjauan Aspek Legalitas Penggunaan Tanda Tangan Elektronik Pada Rekam Medis Elektronik di RS. X Kab. Tasikmalaya

Nazwa Salsabila Azzahra — 2025-08-31

The current era of information technology has penetrated various areas of life, including the health sector, where hospitals are expected to provide not only quality medical services, but also supporting services such as medical records. Medical records, which include patient identity, examination, treatment, actions, and services, have now been transformed into electronic medical records that include electronic signatures . The use of digital signature must meet the legality and security aspects with certification from official electronic certification organizers in Indonesia. This study aims to describe the legality and security aspects of the use of digital signature in medical records at RS. X The study used a qualitative descriptive method with a purposive sampling technique through interviews, observations, and documentation. The results showed that Digital signature at RS. X were divided into two: certified digital signature through BSrE used by doctors for important documents that have legal aspects, and uncertified digital signature used by other health workers with lower legal force. Although the hospital has implemented an information security system such as encryption, VPN, SSL, user whitelist, and routine system maintenance, there is no specific SOP regarding the use of digital signature. The main constraints are network disruptions and reliance on external systems such as BSrE, which can hamper healthcare delivery when systems are inaccessible, forcing hospitals to revert to manual procedures.

Tinjauan Kelengkapan Pengisian Lembar Ringkasan Pulang Resume Pasien Rawat Inap Di RS Permata Cibubur

Fery Kusnadi — 2025-08-31

Quality medical documentation is the foundation of the healthcare system with a direct impact on continuity of care and clinical accountability. The medical resume as an integral component of the medical record serves as a holistic synthesis of therapeutic modalities during hospitalization. This investigation analyzes the completeness of the completion of medical resume documentation through a four-dimensional evaluation: identification modules, clinical reportage segments, authentication elements, and documentation aspects according to standards. This methodology applies a descriptive quantitative paradigm with a cross-sectional survey design on 60 samples of inpatient medical resume documents at Permata Cibubur Hospital during June 2025 using Simple Random Sampling. The research instrument consists of a structured checklist for systematic evaluation through direct observation of the medical resume form. The results of the analysis showed variations in the level of completeness: identification components 95% (5% deficiencies), critical report segments 88.87% (11.13% incomplete), authentication 92.22% (7.78% incompleteness), and proper documentation 93.4% (6.6% incompleteness). The findings show that although the majority of components meet good documentation standards, significant gaps still exist that require systematic optimization. Strategic implications for institutional management include the implementation of a continuous monitoring system and a structured training program for medical personnel to achieve 100% standards in accordance with the Regulation of the Minister of Health Number 24 of 2022.

Tinjauan Pelaksanaan Pengelolaan Visum et Repertum Berdasarkan Prosedur Tetap di Rumah Sakit X Kota Banjar

Indah Heryani — 2025-08-31

Visum et Repertum is an official medical document made at the request of investigators for legal evidence purposes. However, less than optimal management of Visum et Repertum such as improper procedures, incomplete information, and delays in the process can hinder the legal process. This study uses a descriptive qualitative method to understand the implementation of Visum et Repertum management based on Standard Operating Procedure (SOP) at Hospital X, Banjar City. Qualitative research emphasizes understanding natural phenomena that occur in the field so that it is more naturalistic. The descriptive method functions to provide a clear picture of the object being studied without conducting an analysis that produces general conclusions. Thus, this study aims to describe in detail how the management of the Visum et Repertum form is carried out in accordance with the established SOP. The making of Visum et Repertum at Hospital X, Banjar City has been in accordance with the applicable SOP, there are several problems faced by officers in implementing the making of Visum et Repertum. The most requests for Visum et Repertum come from cases of misuse with a total percentage of 45.25% of the total number of cases. There are conformities and non-conformities in the implementation of the making of Visum et Repertum. It is expected that officers can improve the implementation of procedures that are not yet appropriate so that services can be carried out optimally.

Implementasi Teknologi V`Oice Recognition Dalam Dokumentasi Elektronic Health Record (EHR): Studi Kasus Implementasi Sistem Informasi Klinik Bunda Medical Center Pekan Baru

Bachtiyar Wahab — 2025-08-31

Digital transformation in healthcare services demands efficiency and accuracy in patient medical record documentation. One promising innovation is the implementation of voice recognition technology to support the automatic recording of medical data. This study aims to design and implement a voice recognition system within the Electronic Health Record (EHR) application at Klinik Bunda Medical Center in Pekanbaru. The research was conducted from May to July 2025, involving 15 active healthcare professionals as the primary users of the system. The method used was a software engineering approach employing the Rapid Application Development (RAD) model, which included interface design, voice recording feature integration, and limited user testing. The implementation results showed a significant improvement in documentation efficiency, with the average documentation time reduced from 6–8 minutes to 4–6 minutes. Additionally, the completeness of SOAP data increased from 73% to 90%. Most healthcare professionals stated that the system made it easier for them to document data without interrupting patient interaction. However, several challenges were identified, such as reduced accuracy in noisy environments and limitations in recognizing local medical vocabulary. In conclusion, the voice recognition system can be effectively applied to improve the quality of medical record documentation at the clinic level, provided that there is adequate infrastructure support, user training, and continuous evaluation. These findings are expected to serve as a foundation for developing similar systems in other healthcare facilities to accelerate the digitalization of health services in Indonesia.

Indikator Mutu Prioritas Unit Pelayanan Pendaftaran di RSU Bethesda Serukam

Tirzhana Jean Rubina — 2025-08-31

Improving patient quality and safety (PMKP) is a key component in ensuring hospital service quality. One measurement tool used is the quality indicator, which includes the National Quality Indicator (INM), Priority Unit Quality Indicator (IMPU), and Hospital Priority Quality Indicator (IMPRS). The Registration Unit at the Medical Records Installation of Bethesda Serukam General Hospital plays a strategic role in supporting PMKP implementation. However, the unit still requires service improvements to promote systematic quality enhancement. This study aims to design a suitable priority quality indicator for the Registration Unit. A descriptive qualitative method was used, with data collected through interviews, observation, scoring, and Focus Group Discussions (FGD). The study was conducted from November to December 2024 at Bethesda Serukam General Hospital, located at Jalan Raya Singkawang–Bengkayang KM.49, Pasti Jaya Samalantan, Desa Suka Maju, Kecamatan Sungai Betung, Kabupaten Bengkayang, Kalimantan Barat. The results identified the completeness of patient identity data in the Electronic Medical Record (EMR) as the priority quality indicator. This was selected because it met the most criteria, although the current completeness rate is still low (50%). Establishing this indicator is expected to improve service quality, patient safety, and foster a culture of quality at Bethesda Serukam General Hospital.

Analisis Pengolahan Data Morbiditas Guna Menunjang Mutu Pelaporan Rawat Inap di Unit Rekam Medis RS Hermina Arcamanik

Syaikhul Wahab — 2025-08-31

The quality of morbidity reports in hospitals is strongly influenced by the accuracy and completeness of data recorded in the medical record system. In the digital era, the implementation of Electronic Medical Records (EMR) is expected to improve both efficiency and accuracy in reporting. However, in practice, various challenges remain, particularly to due to incomplete data entry by medical staff. This study aimed to analyze the inpatient morbidity data processing at Hermina Arcamanik Hospital and to evaluate the impact of incomplete diagnosis entries on the quality of reporting. A qualitative descriptive method was employed through in-depth interviews, observations, and surveys with medical record officers. The results showed that although the HINAI WEB system had been implemented, inconsistencies in diagnosis entry by physicians led to inaccurate morbidity data. Chronic diseases were dominant in outpatient services, while acute infections were more common in inpatient cases. Caesarean section was the most frequently performed inpatient medical procedure. The study concluded that the success of morbidity reporting is not solely determined by advanced systems, but also by the discipline and active involvement of healthcare workers in accurate and timely data documentation.

Analisis Penyebab Penundaan Klaim BPJS Kesehatan Pasien Rawat Inap Di Rumah Sakit X

Akbar Pratama Setiawan — 2025-08-31

Although digitalization through the Hospital Management Information System (SIMRS) has been implemented, integration with BPJS’s e-claim system remains suboptimal, leaving certain processes manual and prone to errors. Previous studies have identified common causes of pending claims, including incomplete medical documentation and coding errors. However, there is still limited research examining how internal factors—such as staff competency, inter-unit coordination, and the effectiveness of SOPs—interact with external factors like BPJS regulatory changes and system integration challenges. In particular, few studies have focused on RSUP Dr. Hasan Sadikin to explore why pending claims persist despite ongoing digitalization efforts. Therefore, this study aims to conduct an in-depth analysis of the factors causing delays in BPJS Health claims for inpatients at RSUP Dr. Hasan Sadikin Bandung and to propose strategic recommendations to minimize such delays in the future. Using a qualitative approach with a case study method, data were collected through in-depth interviews and document reviews involving administrative staff, claim verifiers, and hospital management. The findings show that delays are mainly caused by mismatches between medical and administrative documents, late data entry by officers, and technical issues in the claim submission system. In addition, insufficient understanding of BPJS procedures and poor coordination between departments also contribute to the problem. To overcome these challenges, the hospital must improve its internal workflow, provide regular staff training, and upgrade its information systems. The results of this study are expected to serve as a reference for hospitals in managing BPJS claims more effectively and ensuring timely service reimbursement.

Variabel Dan Metadata Rekam Medis Elektronik Sebagai Standar Interoperabilitas Data Kesehatan di Rumah Sakit

Rika Andriani — 2025-08-31

Electronic Medical Records (EMRs) require interoperability capabilities to effectively integrate with other health information systems. For EMRs integration, it is crucial to adhere to the guidelines outlined in KMK HK.01.07/MENKES/1423/2022. The implementation of EMRs was carried out in 2019 at Hospital X. Until now, Hospital X has not adjusted the EMRs’ variables and metadata. This study aimed to analyze EMRs’ variables and metadata for health data interoperability. This was a quantitative study. Data collection used a documentation study guideline instrument. Data analysis used descriptive statistic. This study showed that variables and metadata from 5 datasets consisting of emergency, outpatient, inpatient, laboratory, and pharmacy datasets, there were 45,3% exist and appropriate; 20% exist and inappropriate, and 34,7% do not exist compared to KMK HK.01.07/MENKES/1423/2022. To improve the quality of EMRs, it is necessary to adjust variables and metadata in accordance with KMK HK.01.07/MENKES/1423/2022; identify users’ data and information needs; and conduct periodic quality audits and evaluations of EMRs.

Hubungan Kelengkapan Informasi Medis Dengan Keakuratan Kode Diagnosis Penyakit Pada Rekam medis Rawat Inap di RSU Universitas Muhammadiyah Malang Tahun 2024

Endang Sri Dewi Hastuti Suryandari — 2025-09-03

The completeness of medical information such as the medical assessment sheet, examination results sheet, and medical resume sheet greatly influences the accuracy of the diagnosis code. This study aims was to determine the relationship between the completeness of medical information and the accuracy of disease diagnosis codes at the Muhammadiyah University of Malang Hospital. The research’s design was a quantitative analytical research with a Cross Sectional Study approach. The research population were 1134 inpatient medical records (MR). The sample used were 92 MRs using the systematic sampling technique. The independent variable was the completeness of medical information and the dependent variable was the accuracy of the disease diagnosis code. Data were collected through observation in the coding section and used checklist sheets. The outcome showed the completeness of medical information was 67% and the accuracy of disease diagnosis codes was 72%. The Chi Square test showed a relationship between the completeness of medical information and the accuracy of disease diagnosis codes in the inpatient MR at the University of Muhammadiyah Malang Hospital (p-value < 0.05). It is necessary to evaluate the completeness of filling in medical information in MR continuously to improve the accuracy of disease diagnosis codes.