Efektivitas Rekam Medis Elektronik Berdasarkan Kelengkapan dan Intergarsi Sistem di RSUD Dr. Soedarso Tahun 2023

Effectiveness of Electronic Medical Records about Document Completeness and System Integration at Dr. Soedarso Hospital, 2023

Abstract

Introduction: Minister of Health Regulation Number 24 of 2022 requires all Health Service Facilities to maintain Electronic Medical Records. Soedarso Regional Hospital had incomplete medical e-resumes in April – September 2023, an average of 28.9% or 565 of the total 12,607 patient medical records were incomplete each month.

Methods: This descriptive qualitative research involved 17 informants across management, coders, care room staff, and IT personnel. Data collection was conducted through interviews, questionnaires, and observations. Data were analyzed thematically to explore completeness and system integration aspects of EMR implementation.

Results: It was found that an average of 565 (28.9%) documents each month were not filled in completely. The cause of incomplete medical e-resume documents was seen from the HR aspect, namely, 70.8% of respondents who operated the EMR System did not have an educational background in medical recorders, 100% have never received EMR training. The EMR system facility uses two applications, namely MEDIFIRST and SIMRS, which have not been fully integrated with the supporting parts, and there is no EMR SOP in the organizational aspect. It was found that 100% of respondents understood the meaning of EMR in general and knew that incomplete EMR resulted in delays in coding and insurance claims. health

Discussion: Soedarso Regional Hospital uses 2 EMR applications, which are not fully integrated. The human resources who operate it do not have an educational background in medical recorders and have not received training, and there is no SOP as a reference for users. It is recommended to thoroughly integrate the EMR system in related departments, create EMR SOPs, and conduct training for EMR system users.