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Journal : Multidisciplinary Indonesian Center Journal

ANALYSIS OF THE COMPLETENESS OF FILLING IN ELECTRONIC MEDICAL RESUMES FOR INPATIENTS AT DHARMA YADNYA GENERAL HOSPITAL Ni Rai Ayu Tunggal Dewi; Ika Setya Purwanti; Made Wahyu Aditya
Multidisciplinary Indonesian Center Journal (MICJO) Vol. 2 No. 3 (2025): Vol. 2 No. 3 Edisi Juli 2025
Publisher : PT. Jurnal Center Indonesia Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62567/micjo.v2i3.846

Abstract

People really need health services provided by hospitals, health homes and clinics. When registering for health services, each enrolling member will have his or her own medical history which must be seen at a medical clinic or health office. Hospitals must have comprehensive patient data in order to provide health services effectively. Documents regarding patient identity, examinations, treatment, procedures and other services are included in the medical record. In a health facility, implementation takes the form of an administrative order. Characteristics of medical records (General Patients or BPJS). The aim of this research is to determine the completeness of electronic medical resumes seen from fourth aspects, namely, completeness of identification, important reports, authentication and correct documentation . The method used in this research is quantitative analysis with a descriptive approach. The results of this research are that in the Identification component the percentage of completeness is 100% complete, in the Important Report component the percentage of completeness is 99%, in the Authentication component the percentage of completeness is 100%, and in the Correct Documentation component the percentage of completeness is 90%. Based on the results of research that has been carried out regarding completeness When filling out electronic medical resumes for patients in the Inpatients at RSU Dharma Yadnya, it can be concluded that there are still incompleteness in filling out inpatient electronic medical resumes and that the electronic medical resume components are filled in completely.
BRIDGING DOCUMENTATION GAPS IN ELECTRONIC MEDICAL RECORDS: AN ANALYSIS OF INCOMPLETE MEDICAL ASSESSMENTS AND THEIR CONSEQUENCES FOR INA-CBGS REIMBUREMENT Ika Setya Purwanti; Made Wahyu Aditya
Multidisciplinary Indonesian Center Journal (MICJO) Vol. 2 No. 4 (2025): Vol. 2 No. 4 Edisi Oktober 2025
Publisher : PT. Jurnal Center Indonesia Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62567/micjo.v2i4.1475

Abstract

Electronic Medical Records (EMR) are designed to improve service quality, documentation accuracy, and administrative efficiency, including reimbursement through the Indonesian Case-Based Groups (INA-CBGs). However, incomplete medical assessments remain a challenge, potentially leading to service gaps and reduced hospital claims. This qualitative descriptive study was conducted at Dharma Yadnya General Hospital, Denpasar, which has fully implemented EMR since 2024. Data were obtained through in-depth interviews with five informants: two medical record officers, the head of the emergency nursing unit, the head of the inpatient nursing unit, and the head of the medical record department. Data analysis used the 3M framework: Man, Method, and Material. From the Man aspect, heavy workloads of doctors and the lack of administrative support staff often caused delays and incomplete documentation. From the Method aspect, although Standard Operating Procedures (SOPs) and system reminders existed, monitoring relied mainly on manual follow-ups via WhatsApp groups, limiting effectiveness. From the Material aspect, the EMR system was user-friendly and supported by weekly vendor maintenance, but occasional network disruptions and insufficient administrative staff still hampered real-time documentation. Incomplete medical assessments in EMR directly affect INA-CBGs claims, especially when comorbidities, complications, or procedures are not recorded, resulting in under-coding and reduced reimbursement. Strengthening human resources, enforcing SOPs, and improving system support are essential to ensure documentation completeness, service quality, and financial sustainability