Article Per Year (5 Year)
p-Index From 2021 - 2026
0.23
P-Index
This Author published in this journals
All Journal International Journal of Public Health Excellence (IJPHE)
Kesaktian Manurung
Master's Program in Public Health, Direktorat Pascasarjana Universitas Sari Mutiara Indonesia, Medan, Indonesia
Health Professions Medicine & Pharmacology Nursing Public Health

Published : 1 Documents Claim Missing Document
Claim Missing Document
Check
Articles

Found 1 Documents
Search

 1 
Inaccuracies in Paper-Based Medical Record Information: An Exploratory Qualitative Case Study at Putri Hijau Hospital Arie Widiansyah Hasibuan; Myrnawati Crie Handini; Asima Sirait; Donal Nababan; Kesaktian Manurung
International Journal of Public Health Excellence (IJPHE) Vol. 6 No. 1 (2026): June-December
Publisher : PT Inovasi Pratama Internasional

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55299/ijphe.v6i1.2089

Abstract

Paper-based medical records are vulnerable to incomplete, delayed, and inconsistent information, which may hinder data use in care delivery. This study explored medical record information inaccuracies, perceived contributing factors, perceived impacts, and prevention efforts at Rumah Sakit Tk II 01.05.01 Putri Hijau Kesdam I/BB Medan, in 2018. An exploratory qualitative case study used in-depth interviews with four purposively selected informants: a specialist physician, an inpatient ward nurse, a medical records officer, and an inpatient ward general practitioner. Each informant participated in one interview session, totaling 211 minutes. Transcripts were analyzed thematically; analytical decisions were traceable through an audit trail, member checking, and comparison of cross-professional perspectives. Analysis generated 13 substantive codes grouped into four themes. Documentation supported routine care but was not consistently complete or timely. Inaccuracies were perceived to relate to documentation awareness, workflow, service workload, and record verification; they could potentially disrupt continuity of clinical information, administrative processes, data functions, and quality. Prevention requires standard operating procedures, standardized formats, checklists, evaluation, feedback, and cross-professional accountability. The findings offer lessons for improving paper-based documentation and electronic medical record governance during digital transformation, without estimating the prevalence of inaccuracies or overall hospital quality in the single institutional case examined here.
Co-Authors Arie Widiansyah Hasibuan Asima Sirait Donal Nababan Myrnawati Crie Handini