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All Journal Research and Evidence on Knowledge in Administration and Management — Medical Electronic Data and Information Systems
Darmining
Universitas Kadiri
Health Professions

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Relationship of Completeness of Filling Out a Medical Resume with Accuracy of Secondary Diagnosis Codes of Surgical Inpatients Darmining; Windatania Mayasari; Dafrosa Luni; Aldina Ruwari; Gradiana Tafuli
Research and Evidence on Knowledge in Administration and Management — Medical Electronic Data and Information Systems Vol. 1 No. 1 (2025): March, 2025
Publisher : CV. Get Press Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.69855/rekammedis.v1i1.292

Abstract

Coding is an important part of medical records management, significantly affecting reporting accuracy and insurance claim. It was found that incomplete filling of medical resumes by medical personnel caused inaccuracies, especially in secondary diagnosis coding. This study aims to examine the relationship between the completeness of the filling of medical resumes with the accuracy of the secondary diagnosis code in the medical record of surgical hospitalization. Using a descriptive quantitative analytical approach, data were collected through observation of 84 medical records. The observation table served as a research instrument, with the data analyzed by the bivariate method, and The chi-square was used for statistical testing. Results showed 29 records (34.5%) had incomplete medical resumes, while 35 records (41.7%) contained inaccuracies in secondary diagnosis coding. Statistical analysis confirmed a significant relationship between the completeness of medical resumes and the accuracy of secondary diagnosis codes (p = 0.000). These findings suggest that incomplete resume filling negatively affects the quality of secondary diagnosis coding, compromising the validity of medical record data and hospital administrative processes. The study concludes that medical personnel must ensure complete filling of medical resumes to improve coding accuracy and enhance overall hospital record quality.
Analysis of Healthcare Human Resources Capacity in the Management and Quality Assurance of Medical Record Data in the Digitalization Era Weni Tri Purnani; Darmining; Miranty Andrian Deaningsi; Sasa Acnetia; Amanda Putri Anggraini
Research and Evidence on Knowledge in Administration and Management — Medical Electronic Data and Information Systems Vol. 1 No. 2 (2025): September, 2025
Publisher : CV. Get Press Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.69855/rekammedis.v1i2.311

Abstract

The success of Indonesia's digital health transformation critically relies on healthcare Human Resources (HR) capacity and robust Electronic Medical Records (EMR) quality assurance. This study performs an aggregate quantitative analysis using official national data (BPPSDMK, PORMIKI/PPNI) to correlate HR capacity with EMR quality indicators. Results reveal a significant HR imbalance, with 70% concentration in urban areas and a training gap (only 65% of professionals certified/trained). Regression analysis confirmed a strong positive statistical relationship (β=0.75, p<0.01), proving that HR capacity explains 56% (R2=0.56) of the variation in EMR quality. Furthermore, official reports indicate systemic failures in audit trail implementation, including limited access and system instability, compromising data integrity. The strong empirical evidence underscores that sustained, equitable investment in HR training and distribution is the most critical non-technical lever for quality improvement. Therefore, equitable HR development, mandatory standardized audit trail SOPs, and robust digital infrastructure are essential for ensuring high-quality and consistent digital medical record management nationwide.
Co-Authors Aldina Ruwari Amanda Putri Anggraini Dafrosa Luni Gradiana Tafuli Miranty Andrian Deaningsi Sasa Acnetia weni tri purnani Windatania Mayasari