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Journal : PELS (Procedia of Engineering and Life Science)

The Effect of the Completeness of Electronic Inpatient Medical Summaries on the Accuracy of Medical Record Quality at Purwokerto Islamic Hospital Senja, Shafa Mutiara Aulia; Romodon, Dion
Procedia of Engineering and Life Science Vol. 6 (2024): The 3rd International Scientific Meeting on Health Information Management (3rd ISMoHI
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v6i1.1937

Abstract

Background: An electronic medical summary is a concise overview provided by healthcare professionals, particularly doctors, during a patient's treatment period until discharge, whether the patient is alive or deceased. The completeness of electronic medical records is crucial as it impacts the quality of hospital services; incomplete data entry can affect the quality of medical records and the services provided by the hospital.Objective: This study aims to determine the effect of the completeness of electronic medical summaries on the accuracy of medical record quality at Purwokerto Islamic Hospital.Methodology: This research uses a quantitative approach with cross-sectional data collection and a descriptive correlation design. The study sample consists of 89 electronic medical summary forms for inpatient care, selected using simple random sampling. The data was analyzed using the Chi-square test.Results: The study found that the completeness of electronic medical summaries was 89%, while the incompleteness rate was 11%. The accuracy rate was 84%, with an inaccuracy rate of 16%. The primary cause of incomplete electronic medical summaries was missing patient diagnoses. The Chi-square test results showed a p-value of 0.001 (p 0.05). Based on this p-value, the null hypothesis (H0) is rejected and the alternative hypothesis (H1) is accepted, indicating that there is a significant effect of the completeness of electronic medical summaries on the accuracy of medical record quality.