ANALYSIS OF STANDARDIZATION OF VARIABLES AND META DATA OF ELECTRONIC MEDICAL RECORDS AT SANTA ELISABETH BATAM HOSPITAL
Keywords:
Electronic Medical Records, Metadata, Standardization, VariablesAbstract
The application of Electronic Medical Records (EMR) is an essential part of digital transformation in the healthcare sector, mandated by the Ministry of Health Decree No. HK.01.07/Menkes/1423/2022 concerning Metadata and Data Dictionary of EMR. However, in practice, many hospitals still face difficulties in adjusting their EMR variables and metadata to national standards. This study aims to analyze the conformity of outpatient EMR variables and metadata at Santa Elisabeth Hospital Batam with the national standards. This research used a descriptive quantitative approach with a cross-sectional design. Data were collected using checklists on four outpatient EMR forms (patient identity, general consent, payment method, and initial medical assessment), as well as interviews with medical record staff and IT personnel. The results show that from 106 variables analyzed, 33 variables (31.1%) were compliant, 73 variables (68.9%) were non-compliant, and 23 variables (21.6%) were unavailable. Non-conformities were caused by a lack of staff understanding of metadata standards, the absence of specific hospital guidelines, and limitations of the SIMRS used. It can be concluded that the standardization of EMR variables and metadata at Santa Elisabeth Hospital Batam has not yet been fully optimized. Improvements are needed through SOP development, continuous training for medical record staff, and enhancement of SIMRS features in line with national standards.
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References
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Sugiyono. (2019). Metodelogi Penelitian Kuantitatif Dan Kualitatif Dan R&D. Bandung, Alfabeta.
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