Quantitative Analysis of OutpatientElectronic Medical Records (EMR) at Ubung Health Center 2025
DOI:
https://doi.org/10.37824/exqnaf84Keywords:
medical records, outpatients, descriptive, health centerAbstract
Medical records play an important role in supporting healthcare services from administrative, legal, and service planning aspects. The completeness of electronic medical records (EMR), particularly outpatient medical resume forms, greatly determines the quality of services in primary healthcare facilities such as community health centers. Incomplete EMRs can impact referral processes, BPJS claims, and accreditation. Therefore, a quantitative analysis of EMR completeness is necessary. This study aims to analyze the completeness of filling out outpatient medical resume forms quantitatively at Ubung Health Center as a basis for improving the quality of documentation and healthcare services. This study uses a descriptive quantitative method. The population consisted of one thousand two hundred electronic medical record data, with a sample of ninety-two EMR data determined using the slovin formula with a ninety percent confidence level. Data were collected through direct observation using a checklist covering four components: identification, authentication, reporting, and recording. The results showed that, out of ninety-two electronic medical records analyzed, the identification and authentication components were one hundred percent complete. In the reporting component, two records (2.17%) were incomplete in the supporting examination item. In the recording component, one record (1.1%) was incomplete in the error correction item. In conclusion, the overall completeness of outpatient medical resume forms at Ubung Health Center is categorized as good. However, there are still some incomplete aspects in the reporting and recording components, indicating the need for improvements in the documentation process. It is recommended to conduct regular supervision of medical record documentation by staff, increase socialization of documentation completeness procedures among healthcare workers, and strengthen readiness for transitioning toward more accurate and efficient electronic medical records (EMR).
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References
[1] Kementerian Kesehatan Republik Indonesia. (2022). Peraturan Menteri Kesehatan Republik Indonesia Nomor 24 Tahun 2022 tentang Rekam Medis. Jakarta: Kemenkes RI.
[2] Kementerian Kesehatan Republik Indonesia. (2024). Peraturan Menteri Kesehatan Republik Indonesia Nomor 19 Tahun 2024 tentang Pusat Kesehatan Masyarakat. Jakarta: Kemenkes RI.
[3] Kementerian Kesehatan Republik Indonesia. (2023). Profil Kesehatan Indonesia Tahun 2023. Jakarta: Kemenkes RI.
[4] Budi, S. C. (2011). Manajemen Unit Kerja Rekam Medis. Yogyakarta: Quantum Sinergis Media.
[5] Hatta, G. R. (2022). Pedoman Manajemen Informasi Kesehatan di Sarana Pelayanan Kesehatan. Jakarta: Universitas Indonesia Press.
[6] Rustiyanto, E. (2021). Manajemen Filing Dokumen Rekam Medis dan Informasi Kesehatan. Yogyakarta: Graha Ilmu.
[7] Sugiyono. (2022). Metode Penelitian Kuantitatif, Kualitatif, dan R&D. Bandung: Alfabeta.
[8] Zulkarnain. (2021). Metodologi Penelitian Kualitatif. Yogyakarta: Deepublish.
[9] Direktorat Jenderal Pelayanan Medis. (2006). Pedoman Penyelenggaraan dan Prosedur Rekam Medis Rumah Sakit di Indonesia. Jakarta: Departemen Kesehatan RI.
[10] Rahmawati, D. (2022). Implementasi Rekam Medis Elektronik dalam Meningkatkan Efisiensi Pelayanan Pasien. Jurnal Manajemen Informasi Kesehatan Indonesia, 10(1), 45–52.
[11] Rahman, A. (2021). Implementasi Unit Numbering System dalam Pengelolaan Rekam Medis di Puskesmas. Jurnal Rekam Medis dan Informasi Kesehatan, 4(2), 85–92.
[12] Farlinda, S., Nurjannah, N., & Mudiono, D. R. P. (2022). Pengelolaan Rekam Medis dalam Mendukung Mutu Pelayanan Kesehatan. Jurnal Kesehatan, 13(2), 120–127.
