Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)
Vol. 10 No. 1 (2025): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari

GAMBARAN PENERAPAN DAN KELENGKAPAN PENGISIAN REKAM MEDIS ELEKTRONIK RAWAT JALAN DI RUMAH SAKIT TK.II UDAYANA DENPASAR

Suriawan, I Gde Agus Hendra (Unknown)
Devhy, Ni Luh Putu (Unknown)
Aditya, Made Wahyu (Unknown)



Article Info

Publish Date
28 Feb 2025

Abstract

Complete medical record files can facilitate other health workers in providing patient care or treatment, and can be used as, a useful source of information for hospital management in determining the evaluation and development of health aservices. The impact of incomplete medical records is delays in the process of filing insurance claims and delays in the orderly administration process. The purpose of this study was to determine the completeness of filling out the Outpatient Electronic Medical Record at Tk.II Udayana Hospital Denpasar. The research method used is quantitative descriptive with a sample of 95 electronic medical records from July to September 2022 using the simple random samplingOmethod. The resultsashowed that 95 (100%) filled out identification completeness and 0 (0%) incomplete, 92 (96.8%) important report filling completeness and 3 (3.2%) incomplete filling, 69 (72.6%) authentication filling completeness) and 26 (27.4%) incomplete, 71 (74.7%) complete correct documentation and 24 (25.3%) incomplete. It can be concluded from the four analyses, the highest completeness of filling out outpatient RME at Tk. II Udayana Hospital Denpasar is found in important identification and reports. Based on the research above, the researchers suggest that hospitals should conduct socialization regarding the completeness of filling in RME to all health workers who are responsible for filling out electronic medical Records.

Copyrights © 2025






Journal Info

Abbrev

JIPIKI

Publisher

Subject

Health Professions Public Health

Description

Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) (p-ISSN : 2502-7786 ) (e-ISSN : 2597-7156) is a national, peer-reviewed journal. It publishes original papers, reviews and short reports on all aspects of the medical record and health information. It is aimed at all medical record and ...