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The implementation of Hospital Management Information Systems (SIMRS) has become a strategic necessity to improve healthcare service quality and operational efficiency. This study focuses on evaluating the performance of SIMRS in the outpatient registration unit of Nur Hidayah Hospital Bantul, where system disruptions, inconsistent SOP application, and limited user training were identified as core issues. The research aims to assess how well the SIMRS aligns with the Human, Organization, and Technology components through the HOT-Fit model framework. A descriptive qualitative method was employed using purposive sampling to select five informants directly involved in SIMRS operations, including registration officers, IT staff, and the head of the medical records unit. Data were collected through in-depth interviews, direct observation, and documentation, and analyzed thematically based on the HOT-Fit model. The findings show that SIMRS contributes positively to workflow efficiency and data management; however, human factors such as inconsistent training and input errors remain prevalent. Organizational support is visible but lacks structured evaluation routines, and although the technological infrastructure is generally stable, peripheral device and network issues persist. The study synthesizes that effective SIMRS performance requires not only technological readiness but also consistent organizational commitment and continuous human resource development. It concludes that strengthening user competence, formalizing SOP usage, and improving infrastructure are essential to optimize the system's functionality and alignment with the HOT-Fit model.

Electronic Medical Records (EMR) are essential for improving the quality, efficiency, and continuity of healthcare services. Despite mandates requiring full implementation of EMRs in Indonesian healthcare facilities by the end of 2023, many hospitals continue to face challenges in achieving effective adoption. This study aims to analyze the implementation of EMRs in the outpatient services of Nur Hidayah Hospital, Yogyakarta, using the 5M framework: Man, Money, Machine, Materials, and Method. Employing a qualitative descriptive approach, data were collected through in-depth interviews, observations, and document analysis involving key informants from medical records staff, registration officers, and IT personnel. The findings revealed that while the availability of staff and supporting infrastructure such as computers and software was generally adequate, limitations persisted in human resource specialization, training access, and system integration. Financial planning for EMR-related needs was done through annual budgeting (RAB), but coordination between departments remained minimal. Key challenges included slow internet connectivity, limited IT staff, and lack of specific Standard Operating Procedures (SOPs) for EMR usage. Overall, the EMR system has been implemented in most outpatient units, yet not all units have fully transitioned due to technical and organizational barriers. This study concludes that optimizing EMR implementation requires not only technological readiness but also organizational alignment, continuous staff development, and robust inter-departmental coordination.

Electronic Medical Record (EMR) systems have become a fundamental component of hospital information systems, aiming to improve the quality, efficiency, and continuity of patient care. However, the success of EMR implementation depends largely on user satisfaction. This study investigates user satisfaction with the EMR system implemented at Dr. Soetarto (DKT) Hospital, a mid-tier hospital in Yogyakarta, Indonesia. The research addresses issues related to usability, data accuracy, and system responsiveness that potentially hinder effective EMR usage. The objective is to evaluate user satisfaction using the End User Computing Satisfaction (EUCS) framework, which consists of five dimensions: content, accuracy, format, ease of use, and timeliness. A quantitative approach was applied through a structured questionnaire distributed to 40 healthcare workers, including medical records staff, nurses, pharmacists, and administrative personnel. Data analysis using Spearman correlation revealed significant positive relationships among all EUCS dimensions, with the strongest association found between format and ease of use. The findings indicate that while users are generally satisfied with the system’s performance, improvements are still needed in timely data retrieval and user interface consistency. This study highlights the critical need for continuous system evaluation and end-user involvement to optimize EMR functionality and healthcare service delivery.

Background: Incomplete electronic medical record filling by doctors can hinder effective action or treatment by other health workers. This non-compliance problem includes incomplete filling and writing of less specific diagnoses, which can potentially lead to errors in nursing action planning. Purposes: This study aims to test the influence of management commitment and team orientation on compliance in filling electronic medical records with competence as an intervening variable in the inpatient installation of Hermina Hospital, Depok. Methods: This research method is quantitative with a cross-sectional study design. The population is doctors at Hermina Hospital Depok who work in the inpatient installation totaling 133 people. The results of the sample calculation obtained 100 respondents. The data collection technique used a questionnaire, and the analysis method used SEM-PLS. Result: The results of the study showed that management commitment, team orientation, and doctor competence had a simultaneous effect on compliance in filling electronic medical records at Hermina Hospital, Depok. Management commitment and team orientation had a significant effect on doctor competence, which in turn also had a direct effect on compliance in filling out medical records. In addition, doctor competence mediated the relationship between management commitment and team orientation on compliance. Improving doctor competence is the main key to ensuring compliance. Conclusion: The conclusion of this study confirms that to improve compliance in filling electronic medical records at Hermina Hospital, Depok, attention is needed to management commitment and team orientation. Improving doctor competence is the main key in ensuring compliance, with competence functioning as a mediator between management commitment and team orientation towards compliance.

Preeclampsia is a complex illness that can cause health issues and even death for both the mother and the fetus. The three signs of preeclampsia include elevated blood pressure (up to 140/90 mmHg), proteinuria (high protein in the urine), and edema. Preeclampsia is linked to a number of characteristics, including as parity, age, education, occupation, history of hypertension, multiple pregnancies, history of diabetes mellitus, and kidney disease. The purpose of this study is to identify the variables linked to the prevalence of preeclampsia in Tidore Regional Hospital patients who are pregnant or giving birth. This study employs a case control methodology and a descriptive analytical approach. Up to 132 respondents, comprising 66 case groups and 66 control groups, were sampled by accidental sampling. Medical records of moms who had preeclampsia were used as secondary data. A p-value of 0.001 (Sig. <0.05) indicated a relationship between parity and the incidence of preeclampsia; a p-value of 0.001 (Sig. <0.05) indicated a relationship between employment and the incidence of preeclampsia; a p-value of 0.000 (Sig. <0.05) indicated a relationship between the incidence of preeclampsia and a history of diabetes mellitus and kidney disease. preeclampsia at Tidore Regional Hospital with a p-value of 0.042 (Sig. <0.05).

Legal protection of personal health data amidst the rapid digitalization of health services, such as telemedicine, electronic medical records, and online consultation applications is very important. Sensitive health data requires careful management, but in fact, many digital service providers in Indonesia have not implemented adequate security standards. The case of the BPJS Kesehatan participant data leak is a real example of the weakness of the data protection system, coupled with the practice of data misuse by digital platforms without valid consent. The method used is qualitative with a normative legal approach, through a literature study of primary and secondary regulations such as Law No. 27 of 2022 concerning Personal Data Protection (UU PDP), the ITE Law, and related Government Regulations and Permenkes. The results of the study show that although regulations are comprehensively available, implementation in the field still faces serious challenges such as the lack of appointment of Data Protection Officers (DPOs), weak supervision, and low awareness of data protection. Real threats such as cyber attacks, data leaks due to negligence, and misuse by third parties are the main issues. Electronic system providers have a great responsibility in building an information security system, preparing privacy policies, and implementing the principle of "privacy by design".  

Preeclampsia is a condition of hypertension occurring after 20 weeks of gestation, accompanied by organ dysfunction and proteinuria. Preeclampsia is classified into Early Onset Preeclampsia (EOPE), which occurs before 34 weeks of gestation, and Late Onset Preeclampsia (LOPE), which occurs after 34 weeks of gestation. EOPE carries a higher risk of maternal and fetal complications compared to LOPE. This research aims to analyze the complications in mothers and fetuses with EOPE and LOPE that were terminated at RSUD Raden Mattaher Jambi between 2020 and 2022. This descriptive research was conducted in the Medical Records Department of RSUD Raden Mattaher, Jambi, involving 82 patients who experienced both maternal and fetal complications with EOPE and LOPE that were terminated. Sampling was carried out using the total sampling technique based on inclusion and exclusion criteria. The results of this research showed that the prevalence of EOPE was 69.5%, while LOPE accounted for 30.5%. Maternal complications were more commonly found in EOPE cases, including eclampsia (42.1%), HELLP syndrome (36%), premature rupture of membranes (14%), placental abruption (14%), and maternal mortality (5.3%). Fetal complications in EOPE included Respiratory Distress Syndrome (RDS) (10.5%), prematurity (26.3%), low birth weight (29.8%), Intrauterine Growth Restriction (IUGR) (10.5%), and Intrauterine Fetal Death (IUFD) (1.8%). The perinatal mortality rate in EOPE was 7%, with asphyxia recorded in 12.3% of cases. EOPE is more frequently encountered than LOPE and is associated with more severe maternal and fetal complications. Early detection and management of EOPE are crucial to reducing complications and improving pregnancy outcomes.

This study aims to calculate the unit Cost of echocardiography services at RSAL dr. Oetojo Sorong, West Papua, using the Activity-Based Costing (ABC) method and compare it with the applied INA-CBG’s tariff. The research method employed is a quantitative descriptive approach focusing on direct Cost analysis, overhead Costs, and Cost allocation based on activities. The data used includes primary data obtained from direct observation and interviews, as well as secondary data such as financial reports and hospital medical records. The results show that the unit Cost of echocardiography services calculated using the ABC method is higher than the INA-CBG’s tariff, indicating a disparity between the standard tariff and actual Costs. The application of the ABC method provides significant benefits to RSAL dr. Oetojo Sorong, such as identifying Cost-intensive activities, improving operational efficiency, and providing transparency in Cost management. This study also recommends that hospital management evaluate service tariffs and that BPJS Kesehatan review the alignment of INA-CBG’s tariffs with the actual Costs of healthcare services.

The implementation of Electronic Medical Records (EMR) in outpatient services aims to improve the efficiency, accuracy, and accessibility of clinical information. However, the effectiveness of such systems is highly dependent on user satisfaction. This study evaluated the satisfaction of health personnel using outpatient EMR at Sultan Fatah Regional Hospital, Indonesia, by employing the End User Computing Satisfaction (EUCS) model. The research addressed issues related to incomplete data, low system responsiveness, and interface usability that may affect the quality of service delivery. A qualitative descriptive method was used, involving in-depth interviews, direct observations, and document analysis from 21 informants selected purposively across multiple service units. The EUCS dimensions—content, accuracy, format, ease of use, and timeliness—were used to assess user experience. The findings indicate that users encountered problems such as incomplete patient data and duplicate records (accuracy), non-intuitive interfaces (format and ease of use), and delays in accessing medical information (timeliness). Observations and documentation review further revealed a reliance on manual backups and inconsistencies between digital and physical records. Overall, the study highlights the need for better data integration, enhanced user training, interface redesign, and system infrastructure upgrades to ensure real-time and comprehensive EMR usage. The study concludes that addressing technical and human factors through the EUCS model can enhance user satisfaction and system utilization in outpatient healthcare settings.

The implementation of Electronic Medical Records (EMRs) in hospital emergency units is essential to improve the speed, accuracy, and quality of services. However, various challenges hinder optimal system utilization. This study aimed to assess the adoption of EMR at the Emergency Unit of RSUD A.M Parikesit Tenggarong using the Human-Organization-Technology Fit (HOT-FIT) framework. A qualitative descriptive approach was employed involving seven purposively selected informants, including health professionals, administrative staff, and IT personnel. Data were collected through interviews, observations, and document reviews, then analyzed using the Miles and Huberman interactive model. The findings indicate that from the human aspect, the system was considered easy to use (85%), though user satisfaction remained moderate (67.14%) due to system errors and incomplete CPPT data entries. Organizationally, the hospital provided adequate infrastructure and support, though some policies require stronger enforcement. Technological aspects revealed limitations in system stability, lack of pharmacy integration, and low service quality due to frequent downtime. The study concludes that EMR implementation in the Emergency Unit has not yet achieved full effectiveness across all HOT-FIT domains. Improvements are needed in system reliability, information consistency, and inter-unit integration to optimize EMR benefits and enhance patient care delivery in critical settings.

Electronic Medical Records (EMRs) have become a fundamental component of healthcare digitization, offering improved accuracy, accessibility, and efficiency in patient data management. However, the adoption of EMR systems often encounters varied acceptance levels among healthcare workers, particularly in outpatient services where workflow integration is crucial. This study evaluates the implementation of an outpatient EMR system at RSAU dr. Siswanto, Indonesia, using the Technology Acceptance Model (TAM) framework. The research aims to explore users’ perceived usefulness, ease of use, attitude toward usage, behavioral intention, and actual system usage in daily operations. Employing a qualitative descriptive approach, data were collected through in-depth interviews, observations, and document analysis involving doctors, nurses, and medical record staff. The findings reveal that although the EMR system is generally perceived as beneficial for improving documentation and efficiency, several challenges persist, including incomplete feature utilization, limited training, and inconsistent user adaptation across roles. Additionally, network instability and technical downtime were noted as barriers to system reliability. Overall, the study underscores that perceived ease of use and continuous institutional support significantly influence EMR acceptance. These insights highlight the need for targeted capacity building and iterative system development to ensure effective EMR integration in outpatient settings.

Overview: Low Birth Weight (LBW) is a significant health problem in Indonesia because it is at risk of increasing neonatal mortality and morbidity. Objective: This study aims to analyze the risk factors associated with the incidence of LBW in newborns at Prof. Dr. Margono Soekarjo Purwokerto Hospital. Research Method: The method used is an analytical observational study with a cross-sectional design. A sample of 200 mothers and babies was obtained through purposive sampling techniques. Data were collected from medical records and analyzed using the chi-square test and logistic regression. Research Results: showed that prematurity had a partial effect on LBW with a sig value of 0.000 <0.05, and showed that if the incidence of prematurity increased by one percent, assuming the value of other variables remained constant, it would increase the incidence of LBW by 2.769 percent. Variables parity, maternal age, anemia, twin pregnancy, hydramnios, PEB, Placenta Previa, KPD, prematurity, fetal pregnancy simultaneously affected LBW. Conclusion: parity, maternal age, anemia, twin pregnancy, hydramnios, PEB, Placenta Previa, KPD, prematurity, fetal pregnancy simultaneously affect LBW.

The cases of maternal mortality Bogor city in 2022 caused anemia were found to be 30.77%. The purpose the study to determine the relationship between Knowledge, Age, Parity, and History Fe tablet consumption with the incidence of anemia in pregnant women PMB Muthia, Amd.keb Cilendek Barat Bogor Barat, Bogor City in 2024. Research with quantitative approach, cross-sectional design. The sample selected using  total sampling technique. Data collected through questionnaires and medical records consisting 42 respondents. variables of knowledge, parity, age, history Fe tablet consumption, and anemia. The research data were interpreted using Chi Square. Based on the calculation results, was found that among 42 respondents, those with poor knowledge more prevalent the non-anemic group, with 8 people (100.0%), compared anemic group, with 24 people (70.6%). Based on calculation results obtained from 42 respondents, those with age and parity were at greater risk anemia group with 12 people (35.3%) compared to the non-anemia group with 0 people (0.0%). Based calculation results obtained from 42 respondents, those with a history of Fe tablet consumption had higher risk in the anemia group, with 19 people (55.9%) compared non-anemia group, with 3 people (37.5%). There relationship between parity, maternal age, and incidence anemia.

Pregnant women with poor nutritional status or Chronic Energy Deficiency (CED) are at risk of health complications for both the mother and fetus, such as low birth weight (LBW). This study aimed to determine the relationship between pregnant women with CED and the incidence of LBW at RSUD Sultan Muhammad Jamaludin I. The study used a descriptive correlational design with a retrospective approach using secondary data from medical records. The population consisted of 330 respondents, selected by total sampling technique. Univariate and bivariate analyses (Chi-square test) were performed. Most respondents were under 35 years old (66.4%), primigravida (62.0%), in their third trimester (100%), and had tertiary education (54.2%). Most did not have LBW infants (91.8%), and most were not diagnosed with CED (24.1%). Chi-square analysis showed a significant correlation (p=0.001) with an Odds Ratio of 11.566, indicating that CED significantly influences the likelihood of LBW.

This study aims to examine the validity and reliability of user satisfaction measurement for the Electronic Medical Record (EMR) system using the End User Computing Satisfaction (EUCS) approach. The five dimensions analyzed include content, accuracy, format, ease of use, and timeliness. Data were collected from 55 respondents, who were medical records staff at Dr. Moewardi General Hospital. The results show that all dimensions have Cronbach's Alpha values above 0.80, indicating a high level of reliability. The corrected item-total correlations also confirm strong construct validity. These findings demonstrate that the instrument used to measure user satisfaction with the EMR system is both valid and reliable, and can serve as a basis for continuous evaluation and development of health information systems.

Informed consent is a crucial component of medical records that ensures the legality and ethical compliance of medical procedures conducted on patients. At RSUP Surakarta, the completeness of informed consent documentation in the surgical ward has consistently failed to meet the national minimum service standard of 100%, with observed monthly completion rates ranging from 86% to 98% throughout 2024. This study aims to analyze the factors contributing to the incomplete documentation of informed consent in the surgical ward. A qualitative descriptive approach was employed using data collection techniques such as direct observation, in-depth interviews, documentation review, and participatory methods including the USG (Urgency, Seriousness, Growth) prioritization technique and brainstorming. The study involved four key informants: a medical services director, a surgeon, a surgical nurse, and a medical records officer. Findings indicate that the main contributing factors are the absence of Standard Operating Procedures (SOP) for consent documentation, lack of training, insufficient internal and external motivation due to absence of rewards or enforcement measures, limited knowledge, and short tenure of some staff members. The USG analysis identified the absence of an SOP as the most critical issue. Consequently, the development and dissemination of an SOP, coupled with regular staff training, were recommended as corrective measures. This study underscores the importance of structural and motivational support in improving the completeness of informed consent documentation, which is vital for patient safety and institutional accountability.

The implementation of Electronic Medical Records (RME) in hospitals often faces various obstacles that hinder the achievement of maximum benefits. The main problems lie in the visual design, content quality, and user acceptance of the system, which have an impact on the work efficiency of medical personnel and the quality of service to patients. This study aims to analyze the effect of visual design and content quality of RME on Net benefits by considering system users as intervening variables. This research approach uses the HOT-Fit model that integrates human, organizational, and technological dimensions, accompanied by EUCS theory to assess visual and content quality and UTAUT theory to understand user perceptions. The results showed that the dimensions of visual design and content quality had a significant influence on the Net benefits of RME, both directly and through intervening system user variables. The findings also revealed that weaknesses in menu structure and information relevance hindered system performance, although overall, the Net benefits of RME were in the high category. Therefore, continuous evaluation and improvement on visual aspects, such as a more intuitive layout, as well as more organized and relevant content, are priorities for improving RME implementation. Key suggestions include optimizing the menu structure, simplifying navigation, integrating the system across hospital units, and providing ongoing training for system users. Thus, this study contributes to the development of a more effective RME implementation strategy, so as to support digital transformation in the healthcare sector.

Pregnancy is one of the most significant phases in a woman's life, involving both physical and psychological changes. One of the psychological factors that often arise during pregnancy is stress. Stress during pregnancy can affect both maternal health and fetal development, and may even increase the risk of preterm birth. This study aims to analyze the relationship between stress levels in pregnant women and the risk of preterm birth at the UPTD Puskesmas Saritani. The study uses a quantitative design with a descriptive approach, where data was collected from 104 pregnant women screened using the Edinburgh Postnatal Depression Scale (EPDS) and birth status recorded in the medical records of the health center. The results showed that pregnant women who experienced stress had a higher likelihood of preterm birth compared to those who did not experience stress. This study is expected to contribute to the understanding of the impact of stress on maternal and fetal health and provide a foundation for the development of health programs to detect and manage stress in pregnant women, ultimately reducing preterm birth rates.

Background: Anxiety is one of the psychological conditions commonly experienced by pregnant women, especially in the third trimester approaching delivery. Untreated anxiety can affect physiological balance, including increasing the risk of high blood pressure which can develop into complications such as preeclampsia. Objective: This study aims to determine the relationship between anxiety levels and blood pressure in pregnant women in the third trimester. Method: This study used an analytical quantitative design with a cross-sectional approach. The sample consisted of 80 pregnant women in the third trimester selected using a purposive sampling technique at the Fitri Clinic in Batam City. Anxiety level data were collected using the HARS (Hamilton Anxiety Rating Scale) questionnaire, and blood pressure data were obtained through direct measurement and recording from medical records. Bivariate analysis used the Chi-Square test with a significance level of p <0.05. Results: As many as 20% of respondents experienced severe anxiety, and 27.5% had high blood pressure. The results of statistical tests showed a significant relationship between anxiety levels and blood pressure in pregnant women in the third trimester (p = 0.012). Conclusion: There is a significant relationship between anxiety levels and blood pressure during pregnancy. Detection and management of anxiety need to be part of antenatal care services to prevent the risk of pregnancy complications due to increased blood pressure.

Thyroid cancer is the most common endocrine malignancy, with a steadily increasing incidence rate. Although the overall survival rate is relatively high, the risk of recurrence after definitive treatment such as Radioactive Iodine (RAI) therapy remains a significant clinical challenge. Predicting recurrence risk is crucial for optimizing monitoring strategies and interventions. With advances in technology, machine learning (ML) approaches are increasingly utilized to support medical predictions, including the recurrence of thyroid cancer. This study aims to evaluate the performance of four classification algorithms—Logistic Regression, XGBClassifier, Random Forest Classifier, and Voting Classifier—in predicting thyroid cancer recurrence using the Thyroid Cancer Recurrence After RAI Therapy dataset, which consists of 383 patient records and 13 key clinical attributes. The evaluation was conducted using accuracy, precision, recall, F1-score, and area under the curve (AUC) metrics. The results show that the XGBClassifier is the best-performing model with an accuracy of 97.4% and an AUC of 0.95, demonstrating superior performance in handling the minority class. This research is expected to contribute to the development of more effective machine learning–based clinical decision support systems for predicting thyroid cancer recurrence after therapy.