Pengaruh Kelengkapan Resume, Kepatuhan Prosedur Dokumentasi dan Penggunaan Rekam Medis Elektronik terhadap Akurasi Informasi di RS Kemang Medical Care

Desy Lukitawati; Eddy Hermawan Hasudungan Panjaitan; Widya Nengsih

doi:10.30640/inisiatif.v5i3.6738

Authors

Desy Lukitawati Universitas Mitra Bangsa
Eddy Hermawan Hasudungan Panjaitan Universitas Mitra Bangsa
Widya Nengsih Universitas Mitra Bangsa

DOI:

https://doi.org/10.30640/inisiatif.v5i3.6738

Keywords:

Documentation Compliance, Electronic Medical Records, Information Accuracy, Medical Records, Resume completeness

Abstract

The quality of health services is largely determined by the quality of information contained in medical records, where information accuracy serves as a key indicator of hospital service quality. This study aims to analyze the influence of resume completeness, documentation compliance, and the use of electronic medical records on the accuracy of medical record information for discharged patients. A quantitative research method was applied using a total sampling technique involving 100 medical record files of discharged patients. Data were analyzed using the Chi-Square test and Binary Logistic Regression with SPSS version 31. The results of the study indicate that each independent variable has a partial significant effect on information accuracy. Resume completeness shows a significant relationship in the Chi-Square test (p = 0.032), although it becomes not significant in multivariate analysis (p = 0.776). Documentation compliance has a significant effect both in bivariate and multivariate analysis (p < 0.001) with an odds ratio of 5.496. Similarly, the use of electronic medical records also has a significant effect (p = 0.001) and remains significant in multivariate analysis (p = 0.002) with an odds ratio of 4.818. Simultaneously, all variables significantly influence information accuracy (p < 0.001), with an R Square value of 27.8%. Documentation compliance and electronic medical records are the most dominant factors in improving accuracy.

References

Anggraeni, A., & Herlina, I. (2022). Analisis kelengkapan pengisian dokumen rekam medis rawat inap di UPT RSUD Cikalong Wetan. http://ejournal.urindo.ac.id/index.php/kesehatan

Creswell, J. W., & Creswell, J. D. (2022). Research design: Qualitative, quantitative, and mixed methods approaches (5th ed.). SAGE Publications.

Erawantini, F., & Agustina, E. A. (2022). Faktor penyebab ketidaklengkapan pengisian dokumen rekam medis rawat inap di rumah sakit: Literature review. Jurnal Manajemen Informasi Kesehatan Indonesia, 10(1), 104. https://doi.org/10.33560/jmiki.v10i1.403

Ibrahim, M. M. (2024). Tinjauan kuantitatif mutu rekam medis pada formulir discharge summary rawat inap. Jurnal Manajemen Informasi dan Administrasi Kesehatan, 7(2). https://doi.org/10.32585/jmiak.v7i2.5542

Ikawati, F. R. (2024). Efektivitas penggunaan rekam medis elektronik terhadap peningkatan kualitas pelayanan pasien di rumah sakit. https://doi.org/10.38035/rrj.v6i3

Ikawati, F. R. (n.d.). Efektivitas penggunaan rekam medis elektronik terhadap peningkatan kualitas pelayanan pasien di rumah sakit. https://doi.org/10.38035/rrj.v6i3

Indrayadi, I., & Asih, H. A. (2023). Part of incomplete medical record documents: Literature review. Journal of Intelligent Computing & Health Informatics, 4(1), 9. https://doi.org/10.26714/jichi.v4i1.11443

Kemenkes. (2022). Kemenkes 2022. www.peraturan.go.id

Kemenkes. (2024). Kemenkes 2024.

Masyfufah, L., Rosyiari, A. I., Wahyuni, T., Sa’adah, A. A., & Faida, W. (2024). Pemanfaatan resume medis sebagai portofolio kesehatan keluarga. Jurnal Abdimas Jatibara STIKES Yayasan RS Dr. Soetomo, 2(2). https://jurnal.stikes-yrsds.ac.id/index.php/JAJ/article/view/1886

Muhlizardy, M., & Meisari, W. A. (2022). Analisis kelengkapan berkas rekam medis elektronik pada pasien Covid-19 di rumah sakit. RAMMIK: Jurnal Rekam Medik dan Manajemen Informasi Kesehatan, 1(1). https://doi.org/10.47134/rammik.v1i1.10

Mujtahidah, M., & Istiqamah, F. N. (2025). Evaluasi peran rekam medis elektronik dalam meningkatkan kualitas layanan kesehatan dan kepuasan pasien: Literatur review. Graha Medika Public Health Journal, 4(1). https://journal.iktgm.ac.id/index.php/publichealth

Mulyana, M., Situmorang, M., & Natasha, N. (2024). Analisis kelengkapan pengisian RME.

Polit, D. F., & Beck, C. T. (2021). Nursing research: Generating and assessing evidence for nursing practice. Wolters Kluwer.

Santoso, I., & Madiistriyatno, H. (2021). Metodologi penelitian kuantitatif. Indigo Media.

Sari, P. I., Hatta, G., & Nuraini, A. (2023). Analisis pengaruh pengetahuan, kepatuhan dokter dan peran rumah sakit terhadap kelengkapan pengisian berkas rekam medis rawat inap RS Brawijaya. 7(4).

Septi, A. A., Rusdian, I. F., & Ansyori, A. (2024). Implementasi rekam medis elektronik di rumah sakit. Jurnal Kesehatan Amanah, 8(1), 224–231. https://doi.org/10.57214/jka.v8i1.723

Setiyoargo, A., Sigit, N., & Maxelly, R. O. (2022). Peningkatan pengetahuan masyarakat dalam penggunaan resume medis pada fasilitas pelayanan kesehatan. 6(1).

Setyadi, D., & Nadjib, M. (2023). The effect of electronic medical records on service quality and patient satisfaction: A literature review. Journal Research of Social Science, Economics, and Management, 2(12), 2780–2791. https://doi.org/10.59141/jrssem.v2i12.500

Wahyuni, T., & Hariyati, R. T. S. (2024). Sistem pendokumentasian elektronik (SIMRS) dalam upaya peningkatan mutu dan keselamatan pasien: A literature review. Cendekia Medika: Jurnal STIKES Al-Ma’arif Baturaja, 9(1).

Wibowo, A. E., Kurniawan, A., & Nuraini, H. (2021). Metodologi penelitian pegangan untuk menulis karya ilmiah. http://insaniapublishing.com

Wuryanto, S., Nurdiansyah, A. K., & Raharjo, U. D. (2023). Kelengkapan pengisian rekam medis elektronik dalam mendukung ketepatan pengodean diagnosis penyakit. Bhakti Sabha Nusantara, 2(2), 98–107. https://doi.org/10.58439/bsn.v2i2.157