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The Influence of Effective Communication and Patient Safety Culture on Physician Behavior in Filling Out Medical Records with Work Engagement as an Intervening Variable in a Type B Private Hospital in West Jakarta Evi Andani; Hosizah; Rina Mutiara
Al Makki Health Informatics Journal Vol. 2 No. 2 (2024): Al Makki Health Informatics Journal
Publisher : Al Makki Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.57185/hij.v2i2.18

Abstract

This research is based on doctors' disciplinary problems in filling in complete patient medical record data, which has caused several patient safety incidents to occur. The aim of this research is to empirically reveal the influence of effective communication and patient safety culture on doctor behavior with work engagement as an intervening variable. This research is included in quantitative research with a causality approach, the population used is doctors, the sampling technique uses purposive sampling with determining the number of samples using the Slovin formula with an error rate of 5%, so that a sample size of 97 respondents is obtained, with a sampling technique using non-probability sampling . The analysis method uses the three box method and PLS-SEM with the help of the samrt-PLS program. The results of the analysis conclude that work engagement positively intervenes in the influence of effective communication and patient safety culture on doctor behavior, effective communication and patient safety culture have a positive and significant effect on work engagement and doctor behavior, and work engagement is able to influence doctor behavior positively and significant, and also dominates its influence compared to effective communication and patient safety culture.
Design of Electronic Medical Record Data Quality Indicator Dictionary at National Brain Center Hospital Jakarta Fatia Fiqri Wahyuni; Hosizah; Sri Jumiati Agustina
Jurnal Rekam Medis dan Informasi Kesehatan Vol. 8 No. 2 (2025): OKTOBER 2025
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31983/jrmik.v8i2.13218

Abstract

To ensure the quality of Electronic Medical Records (EMR), indicators are needed that function as measuring tools and performance evaluations. These indicators are formulated in the form of an indicator dictionary, which describes operational information to measure performance systematically. Currently, the National Brain Center Hospital (RSPON) does not have an EMR indicator dictionary. Therefore, this study aims to design and test an EMR indicator dictionary, especially in outpatient service units. The study used the Research and Development (R&D) method with the RAND/UCLA Appropriateness Method approach, implemented from November 2024 to January 2025. Based on the method above, the research stages include designing an EMR indicator dictionary using data collection methods through interviews with heads of medical record work units, testing the feasibility of the EMR indicator dictionary using the Delphi technique through a questionnaire involving four experts, and testing EMR indicators through document review of 64 EMR samples. Data analysis used content and descriptive analysis. The results show that the designed indicator dictionary contains operational definitions, data sources, data collection methods, and achievement targets of 100% which are made in accordance with applicable standards. Four experts in the Delphi method agreed that the draft RME indicator dictionary was feasible to use. From the results of the review of 64 RMEs, 50 RMEs (78.13%) were declared complete and on time, while the timeliness indicator separately reached 96.88%. In conclusion, the dictionary of completeness and timeliness indicators is feasible to use as an evaluation tool for filling RMEs in RSPON.
Asesmen Kesiapan Penerapan Rekam Medis Elektronik di RSU Fastabiq Sehat PKU Muhammadiyah Pati Amelia Febriana; Hosizah; Arief Ichwani; Tria Saras Pertiwi
Jurnal Rekam Medis dan Informasi Kesehatan Vol. 8 No. 2 (2025): OKTOBER 2025
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31983/jrmik.v8i2.13841

Abstract

RSU Fastabiq Sehat PKU Muhammadiyah Pati telah mengimplementasikan RME sejak tahun 2017 dengan SIMRS Khanza, namun penggunaannya belum optimal. Meskipun sistem ini telah memiliki fitur yang tergolong lengkap dan memudahkan rumah sakit untuk penggunaan RME. Beberapa fitur RME dalam SIMRS Khanza belum sesuai dengan kebutuhan pengguna. Setiap update modifikasi sistem harus dilakukan secara mandiri dan memerlukan pengecekan menyeluruh terhadap seluruh perangkat yang digunakan. Dalam rangka mengupdate RME diperlukan asesmen kesiapan. Penelitian ini bertujuan untuk menilai kesiapan RME dalam 4 aspek meliputi aspek alur kerja, aspek infrastruktur teknologi (IT), aspek sumber daya manusia (SDM), aspek organisasi. Penelitian ini dilakukan pada bulan September 2024 – Januari 2025. Jenis penelitian Kualitatif menggunakan Metode Qualitative Content Analysis (QCA). Data dikumpulkan melalui wawancara mendalam (in-depth interview) dan observasi dengan 4 informan yang terdiri dari kepala instalasi rawat jalan, kepala tim IT dan staf IT, kepala SDI yang relevan dan keterlibatan langsung dalam proses implementasi RME di instalasi rawat jalan. Analisis data menggunakan MAXQDA Software. Hasil penelitian dari 4 aspek tersebut menunjukkan bahwa pada aspek alur kerja, implementasi RME belum sepenuhnya siap karena belum tersedianya SOP yang sesuai dengan sistem RME, dimana kebijakan yang digunakan masih mengacu pada pedoman rekam medis manual. Pada aspek infrastruktur teknologi (IT), bahwa hardware masih diperlukan adanya UPS (Uninterruptible Power Supply), software sudah memadai namun fitur RME seperti asesmen awal rehabilitasi medik dan asesmen fisioterapi belum sesuai dengan kebutuhan pengguna. Selain itu fitur pendataan hasil echo jantung dan format laporan TB juga belum tersedia. Pada aspek SDM, terdapat 59 pengguna RME yang secara kuantitas dan kompetensi sudah memadai. Penguatan dilakukan melalui pelatihan terstruktur, kolaborasi, dan pendampingan intensif, serta evaluasi berkala oleh bagian SDI. Selain pengguna, terdapat tim pengelola SIMRS yang terdiri dari 19 orang tim adhoc dan 22 orang tim pengembangan. Pada aspek SDM, terdapat 59 pengguna RME dengan kompetensi dan jumlah yang memadai. Penguatan dilakukan melalui pelatihan, kolaborasi, pendampingan intensif, serta evaluasi berkala oleh bagian SDI. Tim pengelola SIMRS terdiri dari 19 orang tim adhoc dan 22 orang tim pengembangan, sementara tim IT berjumlah tiga orang dan masih membutuhkan dua programmer tambahan. Pada aspek organisasi, manajemen menunjukkan komitmen melalui pembentukan kedua tim tersebut yang bertugas mengkoordinasi kendala, menyediakan solusi, dan mengembangkan sistem guna memastikan implementasi RME berjalan optimal.