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Implementation of EMR on the Completeness of Inpatient Medical Records at Oto Iskandar Di Nata General Hospital Sali Setiatin; Mutiara Cinta Sari
International Journal of Psychology and Health Science Vol. 3 No. 3 (2025): International Journal of Psychology and Health Science (July - September 2025)
Publisher : Greenation Publisher & Yayasan Global Research National

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.38035/ijphs.v3i3.1277

Abstract

As health service providers, hospitals have been required to implement an electronic medical record (EMR) system. The goal of implementing an EMR is to improve the accuracy, efficiency, and security of patient medical data. Good medical records are also an indicator of hospital quality, supporting the accreditation process and service efficiency. The author's analysis is motivated by the need to understand the impact of EMR implementation at Oto Iskandar Di Nata General Hospital on the completeness of medical record data. The research method is a descriptive, quantitative analysis with a checklist form as the research instrument. The results showed that the highest percentage of completeness was in the important part of the report with an overall percentage of 89%, while the lowest percentage was in the author authentication section with an overall percentage of 66%. One of the reasons for incompleteness was due to system limitations. In conclusion, although the EMR system has begun to be implemented, the level of data completeness still does not meet the standards set by the Ministry of Health Regulation. 
Analysis of Infrastructure and Human Resources Readiness in the Transition of Outpatient EMR at Sartika Asih Hospital Sali Setiatin; Syakira Ratu Pradesna
International Journal of Psychology and Health Science Vol. 3 No. 3 (2025): International Journal of Psychology and Health Science (July - September 2025)
Publisher : Greenation Publisher & Yayasan Global Research National

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.38035/ijphs.v3i3.1278

Abstract

The transition from manual filing to Electronic Medical Records (EMR) is a strategic step to improve the efficiency and effectiveness of healthcare services. This study aims to analyze the readiness of infrastructure and human resources (HR) in supporting the transition to the EMR system at the Outpatient Department of Bhayangkara Hospital Level II Sartika Asih Bandung. A descriptive qualitative method was used, with data collected through field observations, interviews, and open-ended questionnaires. The results show that the infrastructure, including hardware and information systems, is already available and functioning in each service unit. However, technical issues such as unstable internet connectivity at certain times were still reported. In terms of HR, most healthcare personnel have understood how to use the EMR system through formal training, peer guidance, and direct work experience. The adaptation process has gone relatively well, although there are still differences in comfort levels and technical understanding among healthcare workers. These findings indicate that the overall readiness of infrastructure and HR is at a fairly good level. However, improvements in network quality and equitable distribution of training are still needed to support the successful, comprehensive, and sustainable implementation of the EMR system.
Classification of Inpatient Pending Claim Factors in the RSB Sartika Asih ERM Transition Sali Setiatin; Naila Salsabila Jamilah
International Journal of Psychology and Health Science Vol. 3 No. 3 (2025): International Journal of Psychology and Health Science (July - September 2025)
Publisher : Greenation Publisher & Yayasan Global Research National

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.38035/ijphs.v3i3.1306

Abstract

BPJS claims are the submission of all BPJS patient care costs by healthcare facilities to BPJS. However, the submission of claims may be delayed by the BPJS verifier depending on various factors. This study was conducted at Bhayangkara TK II Sartika Asih Hospital using data on pending inpatient claims from November 2024 to January 2025. The study employed a descriptive, retrospective approach. Non-probability sampling was used to select the entire population. The analysis revealed 327 pending claim files by BPJS. The objective of the research was to identify the factors that caused pending claims during the Electronic Medical Record (EMR) transition period. Data were collected through document analysis and interviews. It was found that the BPJS claims process was not fully EMR-based, resulting in pending claims. Three main factors contributed to this issue: non-compliance with service standards (73%), coding rules (15%), and administrative completeness (11%). These factors disrupt hospital cash flow due to delays in fund disbursement and increase staff workload. To reduce the number of pending claims, it is necessary to routinely evaluate claim data by increasing coordination between related units and promoting compliance with PPK CP to prevent similar mistakes
Analysis Of M-JKN Utilization for Registration Efficiency on EMR Management of RSB Sartika Asih Sali Setiatin; Nadila Nur Umitri
International Journal of Psychology and Health Science Vol. 3 No. 3 (2025): International Journal of Psychology and Health Science (July - September 2025)
Publisher : Greenation Publisher & Yayasan Global Research National

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.38035/ijphs.v3i3.1307

Abstract

The development of digital technology in health services drives the transformation of patient administration and data management systems. One of the innovation ideas in the digitalization era that supports this is the operation of the JKN mobile application managed by the Health Social Security Agency. The use of mobile JKN is expected to be able to drive the efficiency of the electronic medical record process at the Bhayangkara Hospital Class II Sartika Asih Bandung. For this reason, this study aims to examine the elements related to behavior in using and utilizing Mobile JKN efficiently for online registration at the Bhayangkara Hospital Class II Sartika Asih Bandung, it can be observed that there are still many people who do not know about the use of the Mobile JKN application due to the lack of information. However, there are also people who understand Mobile JKN but still fail to register, which is one of the reasons for this study. The research location was at the Bhayangkara Hospital Class II Sartika Asih Bandung and was carried out in April 2025. The research sample numbered 243 people and the sampling used the proportionate stratified random sampling technique.
ANALISIS KESESUAIAN PENGISIAN METADATA ALAMAT PASIEN BARU DALAM MENDUKUNG PENYUSUNAN LAPORAN JANGKAUAN PELAYANAN DI RSUD WELAS ASIH Pinasti Intan Syafitri; Sali Setiatin
Jurnal Mahasiswa Ilmu Kesehatan Vol. 4 No. 3 (2026): Jurnal Mahasiswa Ilmu Kesehatan
Publisher : STIKes Ibnu Sina Ajibarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59841/jumkes.v4i3.3979

Abstract

Electronic Medical Records (EMR) contain patient address data that serves as the foundation for service coverage reporting. This study aims to analyze the compliance of new patient address data entry in supporting service coverage reporting at RSUD Welas Asih. A descriptive quantitative method was employed using simple random sampling, yielding a sample of 392 records. Compliance was evaluated based on Permendagri regulations and analyzed using Microsoft Excel to determine counts and percentages. The results showed that 99% (389 records) of the address metadata were correctly entered, while 1% (3 records) were non-compliant due to typographical errors and regional hierarchy misplacements. Despite the high level of accuracy, the EMR metadata structure at RSUD Welas Asih does not fully comply with KMK No. 1423 of 2022, as it still utilizes alphabetic data types instead of Permendagri numerical codes and lacks separation between ID-based (KTP) and domicile addresses. This condition can hinder automated data grouping and affect report accuracy. Therefore, the EMR system needs to be enhanced by implementing a searchable dropdown feature utilizing standardized regional codes and separating KTP and domicile address variables.
Analisis Beban Kerja Perekam Medis Dalam Masa Implementasi Rekam Medis Elektronik Di RSUD Kesehatan Kerja : Analysis of Medical Recorders' Workload During the Implementation of Electronic Medical Records at the Occupational Health Hospital Salma Salsabila Qurrotaaini; Sali Setiatin
Barongko: Jurnal Ilmu Kesehatan Vol 5 No 1 (2026): Barongko : Jurnal Ilmu Kesehatan (November)
Publisher : Asosiasi Guru dan Dosen Seluruh Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59585/bajik.v5i1.1715

Abstract

Implementasi Rekam Medis Elektronik (RME) di Indonesia masih berada pada tahap transisi sistem hybrid di banyak fasilitas kesehatan, termasuk di RSUD Kesehatan Kerja, sehingga menimbulkan beban kerja ganda bagi petugas Rekam Medis. Penelitian ini bertujuan menganalisis kesesuaian antara jumlah sumber daya manusia (SDM) dengan beban kerja riil petugas Rekam Medis selama masa transisi tersebut. Penelitian menggunakan pendekatan kuantitatif deskriptif dengan metode Analisis Beban Kerja Kesehatan (ABK-Kes), dengan populasi dan sampel seluruh 16 petugas Rekam Medis (total sampling). Data primer diperoleh melalui wawancara, sedangkan data sekunder berupa data ketenagaan dan volume kunjungan pasien periode Januari–Desember 2025. Hasil perhitungan menunjukkan kebutuhan riil SDM sebanyak 26 orang, sementara tenaga yang tersedia hanya 16 orang, sehingga terdapat kekurangan 10 orang (38,5%). Kekurangan paling signifikan terjadi pada kegiatan Distribusi Rekam Medis, Case Mix Rawat Jalan, serta Indeks & Coding. Temuan ini menegaskan bahwa fenomena tugas rangkap yang dialami petugas memiliki dasar objektif, bukan sekadar persepsi subjektif. Manajemen RSUD Kesehatan Kerja disarankan melakukan rekrutmen tenaga secara terarah pada unit-unit dengan kekurangan SDM tertinggi. Dengan demikian, kesenjangan tenaga Perekam Medis memiliki dasar objektif dan perlu segera ditindaklanjuti agar transisi digitalisasi Rekam Medis di RSUD Kesehatan Kerja dapat berjalan lebih efektif, efisien, dan sesuai ketentuan yang berlaku  
Analisis Kelengkapan Dokumentasi Informed Consent ICU Dalam Mendukung Standar HPK 4.1 Di RSU Hermina Arcamanik: Analysis of the Completeness of ICU Informed Consent Documentation in Supporting HPK 4.1 Standards at Hermina Arcamanik Hospital Vira Farihah Aliansyah; Sali Setiatin
Barongko: Jurnal Ilmu Kesehatan Vol 5 No 1 (2026): Barongko : Jurnal Ilmu Kesehatan (November)
Publisher : Asosiasi Guru dan Dosen Seluruh Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59585/bajik.v5i1.1716

Abstract

Standar Akreditasi Rumah Sakit berdasarkan Keputusan Menteri Kesehatan Nomor HK.01.07/Menkes/1128/2022 mewajibkan penerapan informed consent sebagai bagian dari standar Hak Pasien dan Keluarga (HPK) 4.1. Kelengkapan dokumentasi informed consent penting sebagai bukti pemenuhan standar akreditasi serta perlindungan hak pasien. Di ruang Intensive Care Unit (ICU) masih sering ditemukan ketidaklengkapan pengisian formulir. Penelitian ini bertujuan menganalisis kelengkapan dokumentasi informed consent pasien ICU dalam mendukung standar HPK 4.1 di RSU Hermina Arcamanik. Penelitian deskriptif kuantitatif dengan menggunakan 105 dokumen informed consent pasien ICU yang dipilih melalui purposive sampling. Data diambil dari Rekam Medis Elektronik (RME) dengan menggunakan telaah dokumen kemudian dianalisis secara deskriptif menggunakan frekuensi dan persentase. Hasil dari penelitian menunjukkan bahwa autentifikasi memiliki tingkat kelengkapan tertinggi yaitu 95%, sedangkan identifikasi terendah dengan persentase 77%. Ketidaklengkapan pada komponen identifikasi masih memerlukan perbaikan untuk mendukung standar tersebut. Secara umum, dokumentasi informed consent pasien ICU telah mendukung standar HPK 4.1, dengan komponen identifikasi yang masih memerlukan peningkatan.
Analysis Of Inpatient Mortality Distribution Based On Patient Characteristics At Hermina Arcamanik General Hospital In The Second Quarter Of 2026 Adilla Salsabila; Sali Setiatin
International Journal of Health Sciences Vol. 4 No. 3 (2026): IJHS : International Journal of Health Sciences
Publisher : Asosiasi Guru dan Dosen Seluruh Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59585/ijhs.v4i3.1712

Abstract

Inpatient mortality is an important indicator of hospital service quality because it reflects clinical outcomes and patient safety. Mortality data managed by the Medical Records Unit should be transformed into detailed statistical information, not only through Gross Death Rate (GDR) and Net Death Rate (NDR), but also according to patient characteristics and recorded diagnostic patterns. This study aimed to analyze the distribution of inpatient mortality by age, sex, length of stay, treatment unit, and recorded diagnoses, and to calculate GDR and NDR at Hermina Arcamanik General Hospital during the second quarter of 2026. A quantitative descriptive design with total sampling was applied to 153 inpatient mortality cases. Secondary data were obtained through documentary review of mortality recapitulation records from the Medical Records Unit. The findings showed that mortality was most frequently observed among patients aged ≥60 years (51.6%), male patients (57.5%), patients hospitalized for ≥48 hours (75.2%), and patients treated in the Intensive Care Unit (86.9%). Cardiac arrest was the most frequently recorded diagnosis (19.1% of 602 diagnosis entries). The GDR was 21.44‰ and the NDR was 16.11‰, both below the ideal reference thresholds used in the study. These findings indicate that the hospital mortality indicators met the referenced standards during the study period; nevertheless, periodic monitoring and medical audit remain necessary, particularly for high-risk patient groups and critically ill patients.
Analysis Of Electronic Medical Record System Constraint Factors And Inpatient Registration Waiting Time At AMC Cileunyi Hospital Marya Asriadisa Nurobul Tabar; Sali Setiatin
International Journal of Health Sciences Vol. 4 No. 3 (2026): IJHS : International Journal of Health Sciences
Publisher : Asosiasi Guru dan Dosen Seluruh Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59585/ijhs.v4i3.1714

Abstract

Electronic Medical Records (EMRs) are an important component in supporting healthcare delivery, including inpatient registration. Although EMR implementation can make service processes more effective, practical constraints may still disrupt registration and affect patient waiting times. This study aimed to identify constraints in the use of EMRs and describe inpatient registration waiting times at AMC Cileunyi Hospital. A quantitative method with a descriptive observational design was employed. Data were obtained through direct observation of 217 inpatients undergoing registration and interviews with registration staff. The data were analyzed descriptively using frequency distributions and percentages to characterize EMR constraints and registration waiting times. Of the 217 patients observed, 72 patients (33.18%) experienced constraints in EMR use, whereas 145 patients (66.82%) experienced no constraints. By type of constraint, fingerprint verification failure was the most frequently identified problem, affecting 69 patients (31.80%), while BPJS administrative constraints were found in 3 patients (1.38%). Regarding registration waiting time, 140 patients (64.52%) waited ≤15 minutes, whereas 77 patients (35.48%) waited >15 minutes. Thus, most patients did not experience EMR-related constraints and completed registration within 15 minutes. Nevertheless, fingerprint verification remains the predominant constraint, and a substantial proportion of patients still experience waiting times exceeding 15 minutes. These findings may serve as evaluation material for improving EMR system stability and supporting the efficiency and quality of inpatient registration services.
Analisis Kesiapan Sumber Daya Manusia dalam Mendukung Digitalisasi dan Penerapan Rekam Medis Elektronik Sali Setiatin; Muhammad Zahran Ramdhani
Dinasti Health and Pharmacy Science Vol. 3 No. 1 (2025): Dinasti Health and Pharmacy Science (July - September 2025)
Publisher : Dinasti Research & Yayasan Dharma Indonesia Tercinta (DINASTI)

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.38035/dhps.v3i1.2703

Abstract

Perkembangan teknologi informasi telah mengubah pengelolaan rekam medis dari format kertas ke digital, sesuai PMK Nomor 24 Tahun 2022 yang mulai berlaku pada 2023 di RS Kebonjati. Penelitian ini menggunakan pendekatan kualitatif dengan teknik purposive sampling untuk mengumpulkan data melalui observasi, wawancara, dan media pesan. Objek penelitian adalah pengguna Rekam Medis Elektronik (RME), termasuk petugas bagian koder, pelaporan rawat jalan, pelayanan, dan APM. Fokus analisis adalah kesiapan penerapan RME dari segi sumber daya manusia dan infrastruktur di RS Kebonjati. Penelitian bertujuan mengevaluasi kesiapan tersebut dengan tinjauan pustaka. Hasil penelitian menunjukkan bahwa RS Kebonjati cukup siap menerapkan RME, dengan sumber daya manusia yang memadai meskipun memerlukan pelatihan tambahan. Infrastruktur dan aspek finansial sudah ada, tetapi perlu penambahan fasilitas untuk kelancaran digitalisasi Rekam Medis Elektronik (RME), Analisis kebutuhan yang mendalam diperlukan untuk memastikan kesiapan infrastruktur dan kompetensi SDM, agar RS Kebonjati dapat menjadi contoh dalam penerapan RME dan meningkatkan efisiensi layanan kesehatan di masa mendatang.
Co-Authors Abdul Wahab Abdussalaam, Falaah Achmad Alwan Alfarisi Adhita Arif Setyawan Adilla Salsabila Ahmad Fatoni Dwi Julian Ahmad Fatoni Dwi Julian Ai Susi Susanti Aldi Miftahul Rizal Alfarisi, Achmad Alwan Alfarizi, Fikri Ainta Ali Amirudhin Amalia, Melda Amirudhin, Ali Andini Kusdiantini Andira Putra, Sabila Andzara Aulia Aneu Rahma Tunisa Anggi Bela Larita Anisa Nuraulia Annisa Khoifah M Anusuci, Elia Arif Setyawan, Adhita Aris Susanto Aris Susanto Aris Susanto Aris Susanto Aris Susanto Susanto Asep Ma'mun Sanusi Aufa Luthfiyati Aqilah Aulia Nurfadillah Aulia Zeta Andhani Aulia, Andzara Ayu Septiyana Dewi Azizah, Vanny Hendriyan Bhakti Ramadhan Mileniawan Bhakti Ramadhan Mileniawan Bram Burmanajaya Candra Mecca Sufyana Chaedir Pratama Christinawati, Santy Cici Lara Widiya Desy Widyaningrum Dewi, Ayu Septiyana Dewi, Sofia Dian Mardiana Diansyah Dinda Nurul Lita Saptarini Dindin Solehudin Dita Alfiani Widi Saputri Edi Suharto Eka Rusmana, Wempi Elvira, Shinta Erlan Apriyanto Ervien Agus Jakaria Fadhilah, Saeful Fadila Amanda Faris Bastami, Muhamad Fauzi, Muhamad Rizal Fauzia, Rizky Miftah Fuji Sri Hartini Gema Giatsyal Akbar Sya Ghazi Septiandi Gunawan, Sandi Pebrian Hadi Priatmoko Hadiyanti, Rahma Suci Hafizan, Muhammad Ihsan Hakim, Nindia Shalsabillah Hanadia Maheswari Hanadia Maheswari Hendro Hendro Hera Siti Rohmah Herfiyanti, Leni Heri Rukmana Heri Rukmana Herlina Nur Yuniawati Hesti Puspita Sari Ihsan Marga Wiyaksa Indar Farwanti Wahyuni Isna Bidari Israwati Israwati Ivanna Rahmadita Johni S. Pasaribu Kusnadi, Fery Kusuma, Salma Aurellia Latifah, Fania Nazla Nur Latipah, Tania Lita Saptarini, Dinda Nurul Mahendra, Sandy Majdi, Faiq Muhammad Majiid, Nurul Salsasabilla Makaminan, Desviani Marwiyah, Hani Marya Asriadisa Nurobul Tabar Matoeari Soelistijaningroem Mayang Sari Ma’rifatulloh, Rizqi Melda Amalia Moh Arya Putra Ramadhan Muhamad Faris Bastami Muhamad Rizal Fauzi Muhammad Fauzi Rachmatullah Muhammad Ihsan Hafizan Muhammad Zahran Ramdhani Mutiara Cinta Sari Nadia Rizki Pratami Nadia Rizki Pratami Nadila Nur Umitri Nadya Muthiara Putri Naila Salsabila Jamilah Napitupulu, Sagita Noviana Narjati Soejoto, Nina Nina Agustina Ningrum, Intan Septiana Nissa Nurfadilah Norberta Ohoiwutun Novita Krisnawati Nugraha, R. Iqbal Taufik Nur, Ropina Hardian Nuraulia, Anisa Nurfadillah, Aulia Nurul Salsasabilla Majiid Ohoiwutun, Norberta Okky Nur Zahara Pinasti Intan Syafitri Pradesna, Syakira Ratu Prakarsa Al Qadr Saleh, Muhammad Pratama, Sergil Bhakti Purnama, Sandi Rian Putik Cinta Putri Aprilia Kartika Putri, Ismiati Malika Putri, Rizka Auliana Rachmawati, Ghaida Fauziyyah Rahma Aulia Rahma Suci Hadiyanti Rani Muharomah Ratna H, Yunyun Rd. Sekar Putri Defiyanti Rd. Sekar Putri Defiyanti Rena Novia Dewi Rena Resa Yusnia revi rosalinda Rini Suwartika Kusumadiarti Risa Juli Saputra Rita Zulbetti Rizka Auliana Putri Rizky Miftah Fauzia Ropina Hardian Nur rosalinda, revi Rosita Apriyanti Rosita Apriyanti Sabila Andira Putra Saeful Fadhilah Salma Salsabila Qurrotaaini Salwa Rizkiani Syah Sandi Pebrian Gunawan Sandra Laksamana Sandy Mahendra Santy Christinawati Santy Christinawati Sari, Hesti Puspita Sari, Mutiara Cinta Septiani Tri Utami Setiawan, Akbar Pratama Shinta Elvira Sinta Rizki Agustin Siti Insani Siti Lailatul Lutfiah Siti Solihah Soelistijaningroem, Matoeari Solihah, Siti Sri Nurcahyati SRI RAHAYU Surahman Surya Cahyadi Susanto, Aris Susanto Syakira Ratu Pradesna Syifa Qolbiyah Tania Latipah Tania Nurjanah Tasya Farida H Tausiah, Ai Lia Tiara Kusumawardani Trimasuti, Wahyu Tuti Herawati Utami, Septiani Tri Vanny Hendriyan Azizah Vina Anggilia Puspita Vira Farihah Aliansyah Wahyu Trimastuti Wahyu Trimasuti WIDDI SUKMA RAMADHANI Widia Nurrul Irsani Widya Nadiroh Winda Putri Indah Lestari Wirahadi, Umar Yayah Fauziyah Yayang Ayu Nuraeni Yola Nikmatillahi Yola Vandani Imran Yuda Syahidin Yuwanita Kartikaningrum Yuyun Yunengsih Zahran Ramdhani, Muhammad Zulpa Lutfiyyah