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All Journal Research and Evidence on Knowledge in Administration and Management — Medical Electronic Data and Information Systems
Dafrosa Luni
Universitas Karya Dharma Kupang
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.
Implementation Gap Analysis of National Electronic Health Record (EHR) Data Security Standards in Primary Healthcare Facilities Destri Maya Rani; Windatania Mayasari; Riska Faraswati; Dafrosa Luni; Nikmatul Firdaus
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.v1i2.304

Abstract

This study examines the gap between national Electronic Health Record (EHR) data security standards, established by Minister of Health Regulation No. 24 of 2022, and their implementation in Indonesia’s primary healthcare facilities. Secondary data from the Ministry of Health, BSSN, and BPJS Kesehatan (2020–2025) reveal compliance rates of 55%–70%, with significant regional disparities linked to infrastructure and staff training deficiencies. Regression analysis shows staff training intensity (β = 0.54, p = .001) and infrastructure quality (β = 0.47, p = .005) as key predictors, explaining 72% of compliance differences. The findings highlight challenges in technology, human resources, and governance. Urgent integration of technological upgrades and continuous role-based cybersecurity training is recommended to enhance accountability and secure the digital health ecosystem. These insights inform national policy for standardized cybersecurity practices.
Co-Authors Aldina Ruwari Darmining Destri Maya Rani Gradiana Tafuli Nikmatul Firdaus Riska Faraswati Windatania Mayasari