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Asphyxia nonatorum contributed 30.3% to the cause of neonatal death in Central Java Province in 2019, in the case of LBW the percentage was greater than asphyxia neonatoum in cases of neonatal death in Central Java in 2019, namely 46.4%. This research design is quantitative research, with a cross-sectional approach. The sampling technique used the chi-square formula and obtained a sample of 40 respondents. The data collection method used data from medical records. Data analysis used univariate analysis and bivariate analysis using the chi-square test. The characteristics of the respondents were mostly male with a total of 26 babies (65.0%), the majority of the gestational age of the babies in the premature category was 25 people (62.5%). The majority of the babies' mothers had a high school education of 29 people (72.5%), the majority were born by CS procedure of 33 babies (82.5%), with normal amniotic fluid characteristics of 25 people (62.5%). The majority of babies had a weight in There were 22 babies (55.0%) in the LBW category, and the majority of respondents had LBW and moderate asphyxia, 12 babies (54.5%). Based on the analysis results, the d value was 0.518, indicating a moderate positive correlation with a p value (0.000 < 0.05), indicating a relationship between low birth weight and asphyxia at Roemani Muhammadiyah Hospital, Semarang. There is a relationship between low birth weight and asphyxia at Roemani Muhammadiyah Hospital, Semarang.

Introduction: The highest infant mortality rate (IMR) is caused by premature birth. Premature birth can occur spontaneously or through cesarean section that occurs between 20 weeks of gestation and <37 weeks. This study was conducted with the aim of determining the relationship between maternal age and premature rupture of membranes with the incidence of preterm labor. Method: Correlational study (relationship) using a case-control method. Simple random sampling technique was used to select a sample of 118 respondents from a population of 166 mothers who gave birth prematurely at AS Hospital, Kediri Regency in January - December 2022. Patient medical records were used as a source of data collection. Analysis of this study using the Exact Fisher Test correlation test. Results: The relationship between maternal age and the incidence of premature labor was not found to have a significant relationship with the result of 0.725 > 0.05. While the relationship between premature rupture of membranes and preterm labor was found to have a significant relationship with the result of 0.008 < 0.05. Conclusion: There is no significant relationship between maternal age <20 / > 35 years and 20-35 years with premature birth and there is a significant relationship between premature rupture of membranes (KPD) and premature birth at AS Hospital, Kediri Regency in 2022

Electronic Medical Records (EMR) are medical records compiled and stored through an electronic system used to support the provision of healthcare services. The implementation of EMR facilitates faster, more practical, and integrated patient data recording. Electronic Medical Records (EMR) are designed to improve the efficiency, accessibility, and accuracy of patient information within healthcare institutions. This study used a qualitative descriptive approach with a case study design through interviews to assess the readiness of EMR implementation in terms of the 5M management aspects (Man, Money, Material, Machine, Method) at Muhammadiyah General Hospital, Ponorogo Regency. The study sample consisted of 27 healthcare workers selected using a purposive sampling technique. The case study design allowed researchers to capture in-depth insights from healthcare workers directly involved in EMR implementation. The results showed that from the Man element, most healthcare workers were ready to use EMR, as indicated by their comfort and skills in operating the application. In the Money element, there is a system maintenance budget and support for EMR development in the inpatient unit and the Emergency Room. The Material element indicates the availability of adequate software, while the Machine element includes computer devices, internet connections, and a stable server to support users. These technological resources ensure a user-friendly and reliable system. The final element, Method, is demonstrated by the existence of clear SOPs and workflows, enabling healthcare workers to understand and effectively follow the EMR implementation process. Overall, the findings indicate that the hospital is institutionally prepared for EMR adoption.    

Bronchial asthma is a chronic inflammatory disease of the airways that is often triggered by exposure to cigarette smoke, both active and passive. This exposure contains harmful substances such as nicotine, tar, and carbon monoxide that can irritate the airways, increase inflammation, and worsen asthma symptoms. This study aims to determine the relationship between cigarette smoke exposure and the incidence of bronchial asthma in patients at the Pulmonary Polyclinic of Dr. H. Moch. Ansari Saleh Regional General Hospital, Banjarmasin. The research method used a quantitative approach with a cross-sectional design. A sample of 47 patients was selected through purposive sampling according to the inclusion criteria. Data were collected through questionnaires and medical records, then analyzed using the Chi-Square test (α = 0.05). The results showed that the majority of respondents were passive smokers (61.70%), had family members who smoked (57.45%), and were exposed to cigarette smoke daily (55.32%). All respondents had been diagnosed with asthma by medical personnel, and 91.49% reported worsening symptoms after exposure to cigarette smoke. The chi-square test results showed a significant association between cigarette smoke exposure and the incidence of bronchial asthma (p = 0.026). This finding confirms that cigarette smoke exposure is an important risk factor that must be avoided to prevent relapse and worsening of asthma. Therefore, patient and family education regarding the dangers of cigarette smoke, the implementation of smoke-free areas, environmental support, and smoking cessation programs need to be continuously improved as strategies for controlling bronchial asthma.

Preeclampsia is one of the most serious complications in pregnancy, characterized by hypertension and proteinuria, and it poses a significant risk of maternal and fetal morbidity and mortality if not detected and managed promptly. Early detection is crucial, yet clinical diagnosis often faces challenges due to the variability of symptoms and uncertainty in medical decision-making. To address this issue, this study aims to develop an expert system for diagnosing preeclampsia by employing the Dempster-Shafer method, which is known for its ability to handle uncertainty and incomplete information in complex domains such as healthcare. A case study was conducted at Bidadari General Hospital, where data on clinical symptoms and patient medical records were collected and analyzed. The development process of the expert system followed systematic stages, including knowledge acquisition from obstetrics specialists, designing the knowledge base, constructing inference rules, and integrating the Dempster-Shafer algorithm for decision support. The system was subsequently tested using real-case scenarios of pregnant women suspected of having preeclampsia. Evaluation results demonstrated that the system achieved an accuracy rate of 92% in differentiating between preeclampsia and eclampsia, based on belief and plausibility measures combined with symptom analysis. These findings indicate that the proposed system can effectively support medical personnel by providing diagnostic recommendations with a high degree of reliability. In addition, the system offers efficiency in the clinical workflow by minimizing diagnostic errors and reducing delays in treatment initiation. Therefore, this expert system has the potential to become a valuable clinical decision support tool for early detection, risk assessment, and management of preeclampsia. Future development may focus on expanding the knowledge base, integrating real-time patient monitoring data, and enhancing usability to ensure broader applicability in diverse healthcare settings.

Acinetobacter baumannii is a major pathogenic bacterium causing nosocomial infections, known to exhibit high levels of resistance to various antibiotic classes, including β-lactams and aminoglycosides. This widespread resistance poses a significant challenge in hospital patient management, particularly in cases of severe and difficult-to-treat infections. This study aimed to analyze the resistance patterns of A. baumannii to four types of antibiotics in patients with various blood types at Dr. Soeradji Tirtonegoro General Hospital, Klaten. The research method used was a qualitative approach with a case study design. Data were obtained through in-depth interviews with healthcare workers, analysis of patient medical records, and limited observation of clinical practice. The focus of the study was directed at the relationship between patient blood type and the level of antibiotic resistance of A. baumannii. The results showed variations in resistance patterns based on blood type. Patients with blood type AB showed the highest level of resistance to all tested antibiotics, with a prevalence of multidrug resistance (MDR) reaching 85%. In contrast, patients with blood type O showed the lowest resistance and the highest proportion of non-MDR isolates compared to other groups. These findings indicate the role of host factors, namely blood type, in influencing the level of resistance of A. baumannii. The suspected mechanisms involved include differences in surface antigens that influence bacterial adhesion, biofilm formation, and the host immune response. The practical implication of this study is the need to consider blood type as a factor in empirical antibiotic therapy, especially in cases of nosocomial infections caused by A. baumannii.

This study investigates the adoption of Electronic Medical Records (EMR) by registration staff at Tangkiling Health Center, Palangka Raya, using the Technology Acceptance Model (TAM) framework. Out of 61 total healthcare workers, five medical record staff with educational backgrounds in midwifery, nursing, dental nursing, and non-medical high school were purposively selected as research participants. The study employed a qualitative descriptive method, combining in-depth interviews and direct field observations. Results indicate that while the staff acknowledged the usefulness of EMR in improving service efficiency and data accessibility, several barriers hindered its effective use—primarily a lack of training, limited digital literacy, unstable internet connectivity, and inadequate hardware such as computers and printers. Observations showed that only the registration unit had a single shared computer, while other units like outpatient clinics, pharmacy, and cashier still relied on manual documentation. This fragmentation has led to duplicate workloads and disrupted patient data continuity. Despite these challenges, the staff demonstrated a positive attitude and strong behavioral intention to adopt EMR if provided with sufficient infrastructure and regular training. The study concludes that successful EMR implementation in primary healthcare requires not only user acceptance but also institutional readiness, adequate resources, and integrated systems across all service units.

Maternal and Child Health (MCH) remains a major challenge in Indonesia's health sector, given the high maternal and infant mortality rates, largely caused by pregnancy complications. One obstetric complication that requires special attention is Premature Rupture of Membranes (PROM), as it can increase the risk of infection in the mother and fetus and contribute to preterm birth. This study aims to analyze maternal risk factors associated with PROM in the Uteun Pulo Community Health Center (Puskesmas), Seunagan Timur District, Nagan Raya Regency, in 2025. The research method used was a retrospective survey with a quantitative approach. Data collection was conducted through a review of medical records and structured interviews. Fifty-three pregnant women with PROM participated in the study. Data analysis used a chi-square correlation test to examine the relationship between the independent variables and PROM incidence. The results showed a significant association between maternal age and PROM incidence, with a p-value of 0.023 (p < 0.05). Furthermore, parity also had a significant association with the incidence of PROM, with a p-value of 0.013 (p < 0.05). Other findings showed a significant association between maternal age and the frequency of PROM, with a p-value of 0.028 (p < 0.05). These results indicate that maternal age and previous birth history are important factors that need to be considered in PROM prevention efforts in primary healthcare. These findings are expected to inform the development of intervention strategies and education for pregnant women to minimize the risk of pregnancy complications that lead to PROM.

The implementation of Electronic Medical Records (EMR) represents a major advancement in health information systems, playing a vital role in improving service efficiency, data security, and the quality of medical documentation. This study utilizes a literature review approach to assess EMR implementation in hospitals by analyzing findings from 20 relevant journals. Literature sources were obtained from indexed national scientific publications, with a focus on the benefits, challenges, and critical success factors of EMR adoption. The results reveal that EMR use can enhance service efficiency by up to 40%, expedite medical decision-making, and increase the accuracy of patient data. Additionally, EMR reduces the risk of data loss, facilitates coordination among healthcare professionals, and supports more effective integration of medical information. Despite these benefits, EMR implementation encounters several challenges, such as inadequate technological infrastructure, resistance from some healthcare personnel toward digital systems, and the need for ongoing training to ensure optimal use. If not addressed properly, these barriers may limit the system’s effectiveness. Key factors influencing successful implementation include strong management commitment, early involvement of end-users during the planning phase, and system flexibility to meet specific clinical requirements. Therefore, EMR implementation should adopt a holistic approach that integrates human resource readiness, technological capacity, and clear regulatory frameworks. With well-structured strategies, consistent institutional support, and comprehensive training programs, EMR has the potential to be a driving force in the digital transformation of healthcare. This transformation can lead to sustainable improvements in service quality, patient data security, and operational efficiency in hospital settings.

Pulmonary tuberculosis remains a pressing public health problem, particularly in the work area of the Duduk Health Center (UPT Puskesmas). Effective management of this disease requires a thorough understanding of the characteristics of the causes of pulmonary TB in patients. This study aims to classify pulmonary TB cases based on the main causes such as diabetes mellitus, irritant factors, pleural effusion, and family environmental conditions. The research method used is a clustering technique with the K-Means algorithm. The data used are data on pulmonary TB patients in 2020–2025 with variables of age, gender, and causative factors collected from medical records. The analysis process was carried out using MATLAB R2014b software. The clustering model was carried out in 3, 4, and 5 clusters to compare the level of segmentation efficiency. Based on the calculation results, the model with 5 clusters showed the lowest cluster variance value of 0.4889 compared to the 3-cluster model (0.7333) and 4-cluster models (0.6151), which indicates that the division into 5 clusters produces the most compact and representative data group. Each cluster shows a different combination of characteristics of pulmonary TB patients, for example: (1) elderly male patients with comorbid diabetes; (2) adolescent females with the negative influence of environmental factors; (3) adult males exposed to irritants; (4) patients with pleural effusion; and (5) groups with multiple factors. The results of this study can provide strategic input for the Finished Community Health Center UPT in formulating more targeted and targeted intervention policies in order to prevent, control, and handle pulmonary tuberculosis cases in a sustainable and effective manner.  

Minister of Health Regulation No. 269 of 2008 explains that medical records are defined as a collection of documents containing complete information regarding patient identity, examination results, therapy, medical procedures, and health services received. In working, an employee should be able to balance their workload to achieve work harmony that contributes to increased productivity. Job satisfaction reflects the appreciation and comfort felt by an individual for the tasks they perform. Conversely, dissatisfaction at work can trigger negative reactions in the form of aggressive behavior or a tendency to withdraw from social interactions around them. Job satisfaction also greatly influences employee motivation and commitment to continue working with enthusiasm and achieve the desired goals. The purpose of this study was to determine the relationship between workload and job satisfaction with employee performance in the Medical Records Installation of Cut Meutia Hospital, Lhokseumawe in 2023. The research method was an analytical survey with a cross-sectional approach. The study was conducted at Cut Meutia Hospital, Lhokseumawe from September to December 2023. The study population was 40 Medical Records Installation employees. The sampling technique used total sampling, namely 40 respondents. Data analysis used univariate analysis and bivariate analysis. The results of the study based on the chi-square test showed a relationship between workload and employee performance at the Medical Records Installation of Cut Meutia Hospital, Lhokseumawe with a p-value = 0.001 <0.05 and a relationship between job satisfaction and employee performance at the Medical Records Installation of Cut Meutia Hospital, Lhokseumawe with a p-value = 0.000 <0.05. Conclusion; The conclusion in the study is that there is a relationship between workload and job satisfaction with employee performance at the Medical Records Installation of Cut Meutia Hospital, Lhokseumawe in 2023.

A 23-month-old female patient presented with red, itchy bumps, accompanied by intense itching, which caused the skin to peel from scratching. These symptoms began less than a month before the visit and worsened one week before seeking treatment. The fluid-filled bumps burst due to scratching, causing sores and peeling skin. The itching was constant and tended to worsen at night. The use of moisturizer by the patient's mother provided little relief. The onset of these symptoms coincided with a visit from the patient's mother's younger brother, a student at the Islamic boarding school (Santri), who was staying at the patient's home during the holidays. Less than a month later, similar symptoms began to be felt by the patient, her siblings, and both parents. The diagnosis was based on primary data obtained through a history taking with the patient's mother, a direct physical examination during a home visit, and completion of the family file and the patient's medical records. The patient, suspected of having scabies, was treated with 5% permethrin cream, applied as directed, and cetirizine to reduce the itching. Case assessments are conducted holistically, assessing the initial condition, process, and final outcome of each visit both quantitatively and qualitatively. Interventions include not only treatment but also comprehensive family education. This education includes an explanation of the etiology and transmission of scabies, the importance of maintaining personal and environmental hygiene, and potential complications such as secondary skin infections due to scratching. The goal of this education is to improve patient and family compliance with therapy, prevent reinfection, and break the chain of disease transmission in the home environment. This approach is expected to not only reassure the patient but also raise family awareness of the importance of clean and healthy living practices as a long-term preventative measure.

Completeness, suitability, and accuracy in filling medical record documents are essential for effective management of patient files, as well as for improving the overall quality of healthcare services. Medical records serve as a critical tool for documenting patient histories, treatments, and decisions made during their healthcare journey, thus impacting the quality of care provided. Incomplete or inaccurate documentation can lead to delays in treatment, miscommunication among healthcare providers, and legal issues related to patient care. Studies have shown that comprehensive medical records are linked to improved patient outcomes and enhanced operational efficiency in healthcare settings (Smith et al., 2019; Johnson & Patel, 2021). This study aimed to assess the completeness of patient medical record documents in the Medical Resume and Informed Consent forms for inpatients with surgical cases at Tgk. Chik Ditiro Sigli General Hospital. Using a descriptive quantitative approach, the research analyzed a random sample of 293 medical documents. The findings revealed that the completeness of medical record documentation was 69% for the Medical Resume sheet and 83% for the Informed Consent sheet. The study concluded that certain sections were either incomplete or omitted, primarily due to the assumption that certain fields were not applicable to the particular patient’s case. This highlights the need for further training and awareness for healthcare staff regarding the importance of complete medical documentation. The hospital should implement stricter guidelines for filling out medical records and ensure that healthcare workers fully understand the significance of accurate and complete documentation. Future research could explore strategies for improving the consistency of medical record documentation and evaluate the impact of training programs on filling medical records (Williams et al., 2020).

Efforts to realize the implementation of good medical records require supporting elements in the form of medical record folders with a design that meets standards. Medical record folders protect patient documents and simplify the process of identifying, storing, and managing health data. Based on the results of observations at the UMSIDA Physiotherapy Clinic, the medical record folder used is still simple, only made of ordinary paper without a logo, name, clinic address, or columns for writing patient identity and medical record number. This condition has the potential to cause obstacles in the administration and security of patient data. The purpose of this research is to redesign (redesign) medical record folders based on anatomical, physical, and content aspects to make them more professional and functional. The methods used include needs analysis through interviews with users, evaluation of old designs, and the creation of new designs. The redesign was carried out by adding heading elements in the form of the name and address of the clinic, introduction in the form title or medical record folder, and instructions in the form of the text "Confidential Documents." On the body, the patient's identity is contained such as full name and medical record number. From the physical aspect, the folder is designed in the form of a portrait with a size of 21.5 cm × 33.0 cm, using white 260 grams of ivory paper with a blue background. Meanwhile, the content aspects include the identity of the health service facility, the writing "Confidential Document," the patient's name, medical record number, and year of visit. The results of the study concluded that the redesign of the medical record folder has met the anatomical, physical, and content standards needed to support more organized health services.

X Health Center has implemented EMR on SIMPUS since 2009-2010. However, from the preliminary study, it was found that there were obstacles such as network trouble, long loading when many users were pulling data on the system, and there was no SOP for down time: The purpose of this study is to analyze the implementation of Electronic Medical Records at X Health Center, Semarang City in the aspects of Human, Organization, Technology, Net-benefit.  Methods: This study used a descriptive qualitative approach with interviews, observations and documentation studies. Results: The results of research at X Health Center show that there are problems in implementing EMR at X Health Center, in the human aspect, namely system training is still given only to representative officers such as IT and SIK staff. In the organizational aspect, namely limited facilities and lack of manpower. On the technology aspect, namely internet network instability, inconsistent electricity supply and generator unpreparedness and hardware limitations. While in the net-benefit aspect, the implementation of EMR has an impact on increasing the efficiency and effectiveness of X Health Center services. Conclusion: The implementation of electronic medical records at X Health Center is not yet fully optimal, namely in the aspects of human, organization and technology.    

Advances in science and technology have significantly improved and facilitated the work of health professionals. One example is the transition from manual medical records to Electronic Medical Records (EMDR). At Mitra Sejati Hospital, the implementation of EMR still uses manual and electronic methods, so it is not in accordance with the Minister of Health Regulation Number 24 in 2022. This study aims to analyze the implementation of EMR in the mitra sejati hospital on the regulation. The research method used is descriptive qualitative, with observations made using checklist sheets to evaluate the SIMRS application. The research subjects included doctors, nurses, radiology, IT officers, and medical record officers, each represented by one participant. The results of the study showed that the implementation of EMR at Mitra Sejati Hospital was in accordance with the Minister of Health Regulation Number 24 in 2022 about filling in clinical information, inputting financing claim data, and storing EMR. However, the implementation of patient registration, EMR data distribution, information processing, quality assurance, and transfer of EMR contents were not fully in accordance. This discrepancy indicates that the implementation of EMR in the hospital was not fully in accordance with the regulations. To address this gap, special efforts are needed to improve technical systems and staff training, so that it can ensure full compliance with regulations and optimize the function of the EMR.

The leading causes of maternal mortality are thought to include hemorrhage, sepsis, obstructed labor, and hypertensive disease of pregnancy. For many years, demographic and health surveys have been used to study maternal and perinatal health in developing countries. However, few nationwide population surveys have used formally validated questionnaires. Objectives: The purpose of this study was to determine the validity of maternal self-reports of obstetrical complications. Methods: A cross-sectional study was conducted among 300 women at Two Hospitals and one public health center. A questionnaire recorded mothers’ perceptions of obstetrical complications while hospital medical records. Sensitivity, specificity, predictive values, and percent agreement were obtained for obstetrical conditions. Result: In general, women’s reports of obstetrical complications did not match medical diagnoses. The highest agreement was obtained for reporting eclampsia, with less agreement for postpartum haemorrhage. Conclusion: The validity of the survey questionnaires varies between studies due to differences in the questionnaires. Health surveys based on maternal self-report must be interpreted with consideration of this limitation.

Chronic Kidney Disease (CKD) is a major global health issue that can lead to serious complications and long-term medical care. This study aims to identify key clinical factors associated with CKD status using binary logistic regression analysis. The dataset, obtained from Kaggle, contains 400 patient records with various clinical and demographic attributes. The dependent variable is CKD status (positive or negative), while the independent variables include age, blood pressure, hemoglobin level, urine albumin level, and serum creatinine. Initial analysis involved descriptive statistics and multicollinearity checks, followed by model estimation and evaluation using likelihood ratio and Wald tests. The final model identified four significant predictors: blood pressure, hemoglobin, urine albumin, and serum creatinine. The model achieved a high classification accuracy of 95.50% and an Area Under the ROC Curve (AUC) of 98.78%, indicating excellent predictive performance. These results highlight the importance of these clinical indicators in early CKD detection and support their use in risk assessment models for kidney disease screening Keywords: Chronic Kidney Disease, Binary Logistic Regression, Likelihood Ratio Test, Wald Test, Classification Accuracy

Type 2 Diabetes Mellitus (DM) is a disease caused by impaired insulin function, impaired insulin secretion, or both, resulting in a hyperglycemic condition. Patients with type 2 DM generally exhibit characteristics such as a Random Blood Glucose level exceeding 200 mg/dL and an HbA1c  level exceeding 6.5%. The accuracy of medication administration to patients must also consider the rationality of antidiabetic therapy in order to influence the success rate of optimal therapy. This study aims to evaluate the rationality of patient appropriateness and indication appropriateness in outpatients with type 2 DM at Tabanan Regional Public Hospital (RSUD Tabanan). This study employed a semi-quantitative observational research design with a retrospective approach by reviewing patient medical records from the initiation of therapy. Sampling was conducted using purposive sampling, whereby samples had to meet predetermined inclusion criteria. The results indicated that the age group with the highest prevalence of DM patients at RSUD Tabanan was over 56 years old (74%), with a predominance of females (63%). The most common comorbidity among DM patients was hypertension alone (24.5%). Based on the findings, the percentage of patient appropriateness rationality among DM outpatients at RSUD Tabanan was 97.5%, while the percentage of indication appropriateness rationality in type 2 DM outpatients at RSUD Tabanan was 98.5%.

Incomplete medical records remain a significant challenge in achieving efficient and accountable healthcare services. This study aims to design a web-based return system for incomplete medical records at the Medical Record Installation of RSUD dr. DradjatPrawiranegara, Serang Regency. Using data collection through observation, interviews, and literature review, the system is designed to document incompleteness, return processes, and file status tracking digitally. The design results show that the system can speed up the identification and reporting process of incomplete records, improve staff efficiency, and facilitate auditing and archiving. The conclusion is that a web-based system can serve as a strategic solution in managing incomplete medical documents.