Medrec Journal

ANALYSIS OF STANDARDIZATION OF VARIABLES AND META DATA OF ELECTRONIC MEDICAL RECORDS AT SANTA ELISABETH BATAM HOSPITAL

2026-01-23T08:05:27+00:00

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.

THE RELATIONSHIP BETWEEN COMPLETENESS OF DIAGNOSIS AND COMPLETENESS OF EXTERNAL REPORTING OF INPATIENT MORBIDITY AT X HOSPITAL BATAM

2026-01-23T07:48:59+00:00

The completeness of inpatient diagnoses is crucial for generating external hospital reports like RL 4a and RL 5.3. This study aims to analyze the relationship between the completeness of diagnoses and the external reporting of inpatient morbidity at X Batam Hospital. This was a descriptive quantitative study using a cross-sectional approach. The sample consisted of 354 inpatient medical record files in the fourth trimester of 2024, taken using a purposive sampling method. Data was collected through checklists and interviews. From 354 medical record files obtained Percentage of completeness of inpatient diagnosis at Rs X Batam was 86.7% and incomplete was 13.3%. On the other hand, the completeness of external reporting RL 4a and RL 5.3 only reached 97.1% and incomplete was 2.9%. The factors causing incomplete diagnosis in external reporting of morbidity (predisposition) were the lack of training in filling out medical records and socialization of SOP for completeness of filling out medical records. It can be concluded that there is a significant relationship between the completeness of diagnosis and the completeness of external reporting RL 4a and RL 5.3.

THE RELATIONSHIP BETWEEN THE QUALITY OF INFORMATION IN ELECTRONIC MEDICAL RECORDS AND USER SATISFACTION AT HOSPITAL X

2026-02-06T01:48:09+00:00

The implementation of Electronic Medical Records (EMR) in healthcare facilities, including RS X, is mandated by the Minister of Health Regulation No. 24 of 2022 to improve service quality. Although RS X has been using the Khanza SIMRS since 2018, challenges such as data completeness and the transition from manual systems still exist. This study aims to analyze the relationship between the quality of EMR information and user satisfaction. To identify the quality of EMR information, measure user satisfaction with the EMR, and analyze the relationship between the quality of EMR information and user satisfaction at RS X. This analytical quantitative study with a cross-sectional design involved 77 staff members of RS X (nurses, registration officers, midwives) as samples, selected through proportionate stratified random sampling. Data were collected using a Likert scale questionnaire and analyzed univariately and bivariately using the Chi-square test The majority of respondents (70.1%) were satisfied with the quality of EMR information, and 64.9% were satisfied with EMR user satisfaction. Indicators of information quality (completeness, accuracy, readability, timeliness, relevance, consistency) and user satisfaction (completeness, accuracy, format, ease of use, timeliness) showed high satisfaction levels. The Chi-square test (p = 0.040) indicated a significant relationship between information quality and user satisfaction (p < 0.05), with a weak to moderate strength of association (Phi/Cramer's V = 0.234). The quality of information in electronic medical records has a significant relationship with user satisfaction at RS X. Improving the quality of EMR information can enhance staff satisfaction and work efficiency.

THE IMPLEMENTATION OF ELECTRONIC MEDICAL RECORDS ON DIAGNOSIS CODING ACCURACY AT X HOSPITAL

2026-01-26T01:49:22+00:00

The development of information technology has driven the transformation of medical record recording systems from manual formats to Electronic Medical Records (EMR) to improve the efficiency and accuracy of patient data. The accuracy of diagnosis codes is an important indicator in hospital management because it impacts the quality of service, claims processes, and clinical decision-making. This study aims to analyze the effect of EMR implementation on the accuracy of outpatient diagnosis codes at X Hospital. The study used a quantitative descriptive method with a cross-sectional design. The study population was all outpatient medical record files for the period January–March 2025, with a sample of 99 files selected using a purposive sampling technique. Data were collected through an ICD-10-based checklist and interviews with three medical record officers. The results showed that 92% of diagnosis codes were recorded accurately, while the remaining 8% were inaccurate. Factors supporting coding include easier data access, completeness of information in the EMR system, and staff competence in operating the application. Obstacles found were inconsistencies in data entry and limited training. These findings confirm that the implementation of RME has made a positive contribution to increasing the accuracy of diagnostic codes, but efforts to improve the quality of the system and human resource training are still needed to maximize its utilization.

FACTORS RELATED TO PENDING INPATIENT CLAIM AT SEMEN PADANG HOSPITAL

2026-02-24T07:39:21+00:00

Semen Padang Hospital still encounters various obstacles in the implementation of BPJS claim verification, one of which is the rejection of claim files by the verifiers, commonly referred to as pending claims. The aim of this study was to identify the factors associated with inpatient claim pending at Semen Padang Hospital in 2025. This research is an analytical observational study using a cross-sectional approach. The population consisted of all inpatient BPJS claim files at Semen Padang Hospital, totaling 1,741 files, with a sample of 325 files selected through simple random sampling. Data were obtained through observation using a checklist table. The results showed that 26 (8.0%) inpatient medical record claim files were pending. The causes of inpatient BPJS claim pending at Semen Padang Hospital were incomplete claim documents 7 (2.2%), inaccurate diagnosis coding 10 (3.1%), and incomplete supporting examination documents 9 (2.8%). Statistical tests revealed a significant relationship between incomplete claim files and pending claims (p- value = 0.000, p < 0.05), between inaccurate diagnosis codes and pending claims (p-value = 0.000, p < 0.05), and between incomplete supporting examination documents and pending claims (p-value = 0.000, p < 0.05). The conclusion of the study indicates that the factors contributing to pending claims are incomplete claim documentation, inaccurate diagnosis codes, and incomplete supporting examination files. It is recommended that before submitting claims, thorough checks be conducted on the completeness of both claim files and supporting examination documents, and more attention be paid to accurate coding to ensure that the entered codes are appropriate and correct.