International Journal of Health and Pharmaceutical (IJHP)
Vol. 6 No. 3 (2026): August 2026

Evaluation of The Implementation of Electronic Medical Records On The Completeness Of Emergency Room (IGD) Patient Documentation at Lembang Regional Hospital

Dinny Sulistiani (Medical Records and Health Information Study Program, TEDC Polytechnic, Bandung, Indonesia)
Intan Pujilestari (Medical Records and Health Information Study Program, TEDC Polytechnic, Bandung, Indonesia)



Article Info

Publish Date
14 Jul 2026

Abstract

The implementation of Electronic Medical Records (EMR) is part of the digital transformation of healthcare services aimed at improving the quality of documentation and continuity of patient care. This study aims to evaluate the implementation of Electronic Medical Records on the completeness of patient documentation in the Emergency Department (IGD) at Lembang Regional General Hospital. The study used a quantitative approach with a descriptive design and an evaluative approach. The study population was 1,850 Electronic Medical Record documents from ER patients, with a sample of 329 documents determined using the Slovin formula and Simple Random Sampling techniques. Data were collected through observation, documentation studies, and quantitative analysis checklists, then analyzed using descriptive statistics in the form of frequency distribution and percentages. The results showed that the entire ER service documentation process had used Electronic Medical Records. The level of completeness of documentation reached 85.1%, while 14.9% of documents were still incomplete. The most frequently incomplete component was the doctor's signature (10.3%), followed by patient education (6.1%) and physical examination (4.6%). The conclusion of the study shows that the implementation of Electronic Medical Records at Lembang Regional Hospital has supported the completeness of IGD patient documentation, but there is still a need to improve user compliance, monitoring, and evaluation to optimize the quality of medical record documentation

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Journal Info

Abbrev

IJHP

Publisher

Subject

Nursing Public Health

Description

International Journal of Health and Pharmaceutical (IJHP) e- ISSN : 2808-845X is a communication media and scientific publication in the health and pharmaceutical fields published by Inara Publisher. International Journal of Health and Pharmaceutical (IJHP) contains articles from research focusing ...