Electronic medical records (EMR) are part of the digital transformation in the healthcare sector aimed at improving service quality through more efficient and accurate patient data management. This study aimed to evaluate the implementation of electronic medical records and the quality of medical record documentation in a hospital in South Sumatra. This study employed a quantitative approach with a descriptive analytic design. The sample consisted of 100 inpatient medical record documents selected using purposive sampling. Data were collected through observation using a checklist and analyzed using univariate and bivariate analysis with the Chi-Square test. The results showed that the completeness of medical record documentation was 80%, with patient identity having the highest completeness (90%) and physician signatures the lowest (70%). The implementation of EMR was optimal in 60% of cases, while 40% were not optimal. Statistical analysis revealed a significant relationship between EMR implementation and the quality of medical record documentation (p = 0.003). The implementation of electronic medical records contributes to improving the quality of medical record documentation; however, further optimization is needed through improving healthcare personnel competence, strengthening system infrastructure, and conducting regular evaluations.
Copyrights © 2026