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Research and Evidence on Knowledge in Administration and Management — Medical Electronic Data and Information Systems
Published by CV. Get Press Indonesia
ISSN : -     EISSN : 31236952     DOI : https://doi.org/10.69855/rekammedis
Core Subject : Health,
Health Professions
The Journal of Research and Evidence on Knowledge in Administration and Management — Medical Electronic Data and Information Systems (REKAM MEDIS) is an open-access, peer-reviewed scientific journal published by CV. Get Press Indonesia. The journal publishes original research articles, review articles, and case studies in the fields of medical record administration, health information management, and healthcare information systems. Its scope covers medical record management, electronic medical records, health information systems, health informatics, healthcare data analytics, coding and classification systems, telemedicine, data quality and security, legal and ethical aspects of medical records, and the development of human resources in health information services. REKAM MEDIS applies a rigorous peer-review process to ensure the quality, originality, and scientific relevance of all published manuscripts. The journal is published twice a year, in March and September, and provides open access to support the broad dissemination of research findings. REKAM MEDIS aims to serve as a trusted platform for researchers, academics, practitioners, and policymakers in advancing knowledge and innovation in medical records, health information management, and healthcare information systems.
Arjuna Subject : -
Articles 13 Documents
 1   2 
An Overview of the Completeness and Clarity of the Writing of Medical Actions in the Accuracy of the Code of Actions in the Surgical Ward at Lubuk Basung Hospital Made Dewi Sariyani
Research and Evidence on Knowledge in Administration and Management — Medical Electronic Data and Information Systems Vol. 1 No. 1 (2025): March, 2025
Publisher : CV. Get Press Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.69855/rekammedis.v1i1.289

Abstract

Medical coding is a vital part of hospital information systems, converting clinical data into standardized codes such as ICD-9-CM. The accuracy of these codes is strongly influenced by the completeness and clarity of medical procedure documentation. This study aims to assess the completeness and clarity of procedure documentation in relation to coding accuracy in the surgical ward of Lubuk Basung Hospital. A descriptive quantitative method was used, with data collected through observation of 61 medical records out of 155, selected via accidental sampling. A checklist table was used as the research instrument, and data were analyzed univariately. Results showed that 39 records (63.9%) had incomplete documentation, while 22 records (36.1%) were complete. In terms of clarity, 30 records (49.2%) were unclear, and 31 (50.8%) were clear. Regarding coding accuracy, 32 records (52.5%) were inaccurate, and 29 (47.5%) were accurate. These findings indicate that the level of accuracy of coding medical procedures is still relatively low and has a close relationship with documentation problems, especially those related to aspects of completeness and clarity of information. The study underscores the need to improve documentation quality by healthcare providers and to enhance coding accuaracy by coding staff. Strong collaboration between medical teams and coders is essential to ensure accurate data and support high-quality hospital services.
Helpdesk Application Design Electronic Medical Record Reporting Antik Pujihastuti; Eni Efanti
Research and Evidence on Knowledge in Administration and Management — Medical Electronic Data and Information Systems Vol. 1 No. 1 (2025): March, 2025
Publisher : CV. Get Press Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.69855/rekammedis.v1i1.290

Abstract

The number of EMR users in RSUP Dr. M.Djamil Padang often occur disorders such as application errors, EMR hank or application can not be opened, employee/user complaints about the problem is not known to have been done. Purpose: This study aims to design a helpdesk application to streamline the reporting of electronic medical record issues, thereby addressing the existing problems. Methods: This study employed a Research and Development (R&D) method. The research was conducted at Dr. M. Djamil Hospital Padang. Data were collected through observations and interviews with two key 2 informants: the head of the Hospital Information System (SIMRS) and one IT staff. A checklist table was also utilized. The application was designed using the waterfall development method. Results: he resulting helpdesk application for electronic medical record (EMR) issues reporting was developed in line with the workflow of the existing EMR reporting process. The helpdesk comprises four main components: user data, report data, problem solving data, and reporting data. Implications: the helpdesk application is necessary to ensure optimal coordination of users and the EMR manager, thereby minimizing the problems that occur. Conclusion: the designed helpdesk application successfully addresses EMR reporting issues that were previously handled manually.
Implementation of Physical Medical Record Storage System as the Basis for Integration with the Electronic Medical Record System (RME) Sri Inti; Riska Faraswati; Nikmatul Firdaus; Futri Januarti Aspandi; Enjelita Rambu
Research and Evidence on Knowledge in Administration and Management — Medical Electronic Data and Information Systems Vol. 1 No. 1 (2025): March, 2025
Publisher : CV. Get Press Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.69855/rekammedis.v1i1.291

Abstract

In the digitalization era, transforming Hospital Information Systems presents challenges in managing physical medical records, including limited digital infrastructure, unprepared human resources, and difficulties integrating manual systems with digital technologies. These challenges pose risks to data accuracy, accessibility, and patient safety during the shift toward more efficient and secure digital systems. Purpose: This study aims to evaluate the storage and management system of physical medical records amid the digitalization process and identify barriers and potential integration with digital systems. Method: A qualitative approach was used through a case study in a regional public hospital. Data were collected via in-depth interviews, observations, and document analysis. Results: Findings indicate that hospitals still rely on physical medical records due to limited infrastructure, cybersecurity concerns, and insufficient staff training. About 65% of respondents identified patient data protection as a major issue, while limited training reduced the effectiveness of electronic system implementation. Implications: The findings emphasize the need to strengthen IT capacity and provide ongoing staff training, supported by budgets for infrastructure and skill development. Conclusion: Although digitalization is inevitable, physical medical records remain essential during the transition. Integration can be achieved through hybrid systems using technologies such as barcode scanning to enhance data accuracy, efficiency, and security.
Relationship of Completeness of Filling Out a Medical Resume with Accuracy of Secondary Diagnosis Codes of Surgical Inpatients Darmining; Windatania Mayasari; Dafrosa Luni; Aldina Ruwari; Gradiana Tafuli
Research and Evidence on Knowledge in Administration and Management — Medical Electronic Data and Information Systems Vol. 1 No. 1 (2025): March, 2025
Publisher : CV. Get Press Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.69855/rekammedis.v1i1.292

Abstract

Coding is an important part of medical records management, significantly affecting reporting accuracy and insurance claim. It was found that incomplete filling of medical resumes by medical personnel caused inaccuracies, especially in secondary diagnosis coding. This study aims to examine the relationship between the completeness of the filling of medical resumes with the accuracy of the secondary diagnosis code in the medical record of surgical hospitalization. Using a descriptive quantitative analytical approach, data were collected through observation of 84 medical records. The observation table served as a research instrument, with the data analyzed by the bivariate method, and The chi-square was used for statistical testing. Results showed 29 records (34.5%) had incomplete medical resumes, while 35 records (41.7%) contained inaccuracies in secondary diagnosis coding. Statistical analysis confirmed a significant relationship between the completeness of medical resumes and the accuracy of secondary diagnosis codes (p = 0.000). These findings suggest that incomplete resume filling negatively affects the quality of secondary diagnosis coding, compromising the validity of medical record data and hospital administrative processes. The study concludes that medical personnel must ensure complete filling of medical resumes to improve coding accuracy and enhance overall hospital record quality.
The Relationship Between the Completeness of Medical Records and the Quality of Patient Care in Health Centers Siswi Wulandari; Bram Mustiko Utomo; Ayu Tiska Arlik; Mar'atus Sholihah; Pipit Andriyani
Research and Evidence on Knowledge in Administration and Management — Medical Electronic Data and Information Systems Vol. 1 No. 1 (2025): March, 2025
Publisher : CV. Get Press Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.69855/rekammedis.v1i1.295

Abstract

The quality of healthcare services in Primary Health Centers (Puskesmas) is strongly influenced by the completeness of medical records, which are essential for ensuring continuity, safety, and accountability of patient care. Complete documentation supports accurate clinical decision-making and service evaluation. Purpose: This study aimed to analyze the relationship between medical record completeness and the quality of patient care in Puskesmas in the Yogyakarta Special Region. Methods: A quantitative cross-sectional study was conducted involving 100 patient respondents. Data were collected through medical record audits to assess documentation completeness and validated service quality questionnaires to measure patients’ perceptions of care quality. The association between variables was analyzed using the Spearman Rank correlation test with a significance level of 0.05. Results: Only 38% of medical records were classified as complete. However, the analysis showed a significant positive relationship between medical record completeness and patient care quality (r_s = 0.624; p = 0.001). Conclusion: Medical record completeness plays a critical role in improving healthcare quality in Puskesmas and should be strengthened through systematic documentation management and continuous staff training.
Correlation between Medical Record Completeness and Inpatient Length of Stay Efficiency Based on Secondary Data from Vertical Hospitals Sri Inti; Erike Yunicha Viridula; Rini Damayanti; Alfiah Ramadhani Amran
Research and Evidence on Knowledge in Administration and Management — Medical Electronic Data and Information Systems Vol. 1 No. 2 (2025): September, 2025
Publisher : CV. Get Press Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.69855/rekammedis.v1i2.303

Abstract

This study investigates the relationship between medical record completeness and inpatient Length of Stay (LOS) efficiency in Indonesian vertical hospitals managed by the Ministry of Health. Using a quantitative descriptive correlational design, data from 150 hospitals collected during 2023–2024 were analyzed. Pearson’s correlation analysis revealed a significant negative relationship (r = −0.62; p < 0.001), indicating that higher levels of medical record completeness are associated with shorter LOS. These results underscore the essential role of accurate and comprehensive documentation in improving clinical workflow, expediting decision-making, and enhancing hospital efficiency. The findings also highlight the importance of adopting Electronic Medical Records (EMR) and implementing continuous data audits to support quality improvement. Policymakers are encouraged to strengthen infrastructure, training, and digital transformation initiatives to ensure sustained improvements in national hospital performance.
Implementation Gap Analysis of National Electronic Health Record (EHR) Data Security Standards in Primary Healthcare Facilities Destri Maya Rani; Windatania Mayasari; Riska Faraswati; Dafrosa Luni; Nikmatul Firdaus
Research and Evidence on Knowledge in Administration and Management — Medical Electronic Data and Information Systems Vol. 1 No. 2 (2025): September, 2025
Publisher : CV. Get Press Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.69855/rekammedis.v1i2.304

Abstract

This study examines the gap between national Electronic Health Record (EHR) data security standards, established by Minister of Health Regulation No. 24 of 2022, and their implementation in Indonesia’s primary healthcare facilities. Secondary data from the Ministry of Health, BSSN, and BPJS Kesehatan (2020–2025) reveal compliance rates of 55%–70%, with significant regional disparities linked to infrastructure and staff training deficiencies. Regression analysis shows staff training intensity (β = 0.54, p = .001) and infrastructure quality (β = 0.47, p = .005) as key predictors, explaining 72% of compliance differences. The findings highlight challenges in technology, human resources, and governance. Urgent integration of technological upgrades and continuous role-based cybersecurity training is recommended to enhance accountability and secure the digital health ecosystem. These insights inform national policy for standardized cybersecurity practices.
Assessing the Quality Gap in Medical Record Data between Underdeveloped and Non-Underdeveloped Regions based on National Health Reporting Quality Indicators Bram Mustiko Utomo; Siswi Wulandari; Arum Sukma; Maria Yasinta Dobhe; Clara Anabel Galla
Research and Evidence on Knowledge in Administration and Management — Medical Electronic Data and Information Systems Vol. 1 No. 2 (2025): September, 2025
Publisher : CV. Get Press Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.69855/rekammedis.v1i2.305

Abstract

Accurate medical record data is crucial for effective healthcare and evidence-based policy in Indonesia. This study aimed to quantify the significant quality discrepancies—in completeness, accuracy, and timeliness—persisting between the underdeveloped 3T regions (Tertinggal, Terdepan, Terluar) and non-3T counterparts. We utilized a comparative design and analyzed multisource secondary data from the Ministry of Health, BPS, and BPJS Kesehatan (2023–2024), employing ANOVA and regression analysis on validated national reporting quality indicators. Results unequivocally demonstrate that 3T regions significantly lag non-3T areas across all metrics ($p < 0.001$). Regional classification was a powerful predictor, independently accounting for $38\%$ of the variance in overall data quality (Adjusted $R^2 = 0.57$). These findings underscore the urgent need for targeted resource allocation toward digital infrastructure and capacity building in 3T regions to foster equity in health information systems, which is paramount for advancing Indonesia’s commitments to Universal Health Coverage (UHC) and the SDGs.
The Impact of the Latest Health Data Privacy Regulations on Patient Information Access Policies in Healthcare Service Facilities Antik Pujihastuti; Yuyun Manggandhi; Khofifah Rafika
Research and Evidence on Knowledge in Administration and Management — Medical Electronic Data and Information Systems Vol. 1 No. 2 (2025): September, 2025
Publisher : CV. Get Press Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.69855/rekammedis.v1i2.306

Abstract

This investigation scrutinizes the impact of Indonesia's Law No. 27 of 2022 (UU PDP) on patient information access policies in healthcare institutions. Employing a qualitative methodology based on secondary data content analysis of national statutes, ministerial regulations, and professional guidelines, the study assesses the legal and ethical ramifications for clinical data management. Key findings indicate a significant strengthening of patient rights, evidenced by mandatory explicit consent and the implementation of role-based access protocols, coupled with advanced security adoption in large hospitals. Conversely, regional facilities confront considerable challenges from limited infrastructure and inadequate human capital, leading to elevated data breach susceptibility. Persistent legal enforcement issues and ethical dilemmas necessitate continuous training and clear operational guidelines. The research emphasizes the critical need for integrated enforcement, technical modernization, and coordinated stakeholder action to ensure the secure and equitable handling of patient data, aligning with international standards. Future research should focus on scalable technological and ethical awareness solutions.
The Efficacy of Utilizing BPJS Health Claim Big Data on the Accuracy of Diagnosis Coding in Type B Hospital Medical Records Fauzia Laili; Siti Aminah; Siswi Wulandari; Khofifah Rafika; Nadia Vivi K
Research and Evidence on Knowledge in Administration and Management — Medical Electronic Data and Information Systems Vol. 1 No. 2 (2025): September, 2025
Publisher : CV. Get Press Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.69855/rekammedis.v1i2.308

Abstract

The pervasive problem of diagnostic coding inaccuracies significantly impacts the financial integrity and efficiency of Indonesia's National Health Insurance (JKN) system in Type B hospitals. This study aims to assess the efficacy of utilizing large-scale BPJS Health claims data to improve coding accuracy and identify its key determinants. A quantitative, retrospective secondary data analysis was conducted on 150,000 claim records spanning 2020–2024. Big Data analytics employing Random Forest (RF) and Classification and Regression Tree (CART) models successfully detected coding discrepancies, achieving an overall accuracy of 87.2% for primary diagnoses. Statistical analysis indicated that the maturity of the Electronic Medical Record (EMR) system (p<0.01) and staff ICD-10 training (p<0.05) are highly significant determinants. Crucially, the application of this predictive analysis resulted in a 12% reduction in coding errors compared to historical methods. In conclusion, the utilization of BPJS claim Big Data substantially enhances coding accuracy and reliability, confirming the necessity of integrating data-driven technology with simultaneous investments in digital infrastructure and continuous human capacity building for the sustainable quality improvement of the Indonesian health system.

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