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Community health services are the most important part of supporting community health. Puskesmas is a health institution that is very close to the community. Therefore, it is important to pay attention to supporting facilities and infrastructure in the medical records work unit such as work equipment, work procedures, work processes or systems, work environment, employee physiology and psychology so that medical records officers more productive at work. Based on observations made at the West Baktiya Community Health Center, it was found that the area of the medical records unit was 5 x 5 m2 with a ceiling height of 3 m, using a white ceramic floor, there were 6 windows, 1 door, 2 staff work desks and 3 cupboards for Save correspondence and other important documents. Lighting in the medical records unit room is 259 lux, noise is 53.3-62.0 dB, temperature in the medical records unit room is 33.1oC and humidity is 70%. In the medical records unit room there are no chemical substances in solid, liquid or gas form, and there are also no vectors or disease-carrying animals such as flies, mosquitoes, cockroaches and rats. The aim of this activity is to provide outreach regarding ergonomics in the medical records work unit at the West Baktiya Community Health Center. The implementation method consists of planning, implementation actions, evaluation and activity report preparation stages. The result of this service is that it can increase the knowledge of medical records officers and other healt

Technology that develops very rapidly brings many changes, especially in the development of medical records in hospitals that are increasing. Electronic medical records bring many benefits, one of which is improving the quality of services in hospitals. The medical records used at Hermina Arcamanik Hospital are mostly electronic-based, including reporting. However, problems were found in the medical record installation, namely, there were several reports that had not been managed optimally. This is because reporting still uses google spreadsheets which requires data to be moved manually one by one, so it takes a long time, and the quality of reporting becomes less accurate. A real example of this problem can be seen in the process of reporting patient Mortalitys. Meanwhile, accurate and systematic reporting of Mortality data is essential in supporting decision-making in hospitals. Therefore, the design of a patient Mortality reporting information system is urgently needed to make time efficient and improve the quality of reports. The method used in designing this system is extreme programming and web-based. The results of this information system design are able to shorten the time to make Mortality reports and can produce accurate data

Background: The implementation of Electronic Medical Records (RME) in healthcare facilities still faces a high failure rate, with more than 50% of RME systems not being used optimally. Sawah Besar Hospital, which began implementing RME in August 2023, recorded 1,500 cases of errors in a year, with 60% of system errors and 30% of user errors. This study aims to analyze the factors that affect the intention of using RME by nurses by integrating the Technology Acceptance Model (TAM) and the Theory of Planned Behavior (TPB). This quantitative research uses a census method by involving 70 nurses as respondents. Data were collected through questionnaires and analyzed using path analysis. The results showed that perceived ease of use, perceived usefulness, subjective norm, perceived behavioral control, and attitude toward use simultaneously affected the intention to use RME (F=77.917, p<0.05). Attitude toward use acts as a mediator in the relationship between perceived ease of use and perceived usefulness to the intention to use RME. These findings have important implications for hospital management in optimizing the implementation of RME through improving technical aspects and forming positive user attitudes.

This study aims to design and implement a web-based outpatient registration information system at Regional General Hospital (RSUD) X to overcome issues arising from the manual registration system. The current manual registration system at RSUD X causes problems such as long queues, potential data entry errors, lost files, and difficulty in finding patient medical history. As a result, patient waiting times are longer, the administrative staff's workload increases, and the overall effectiveness of services decreases. The research method used is a qualitative one, which describes various processes in the system, from patient data input to the digital registration receipt output. The system design approach uses the waterfall method. Data collection was carried out through purposive sampling, while data gathering was done through interviews with registration officers, direct observation, and a documentation study in the medical records unit. The system is built with a combination of technologies, including PHP as a server-side programming language and MySQL as the database. The result is a web-based outpatient registration information system that can improve the efficiency and quality of hospital services. The advantages of this system include wide accessibility, time efficiency, and effective data management. This system is expected to reduce patient queues, improve the efficiency of the registration process, and simplify patient data management. However, the implementation of this system may face challenges such as limited resources and user skills. Solutions to overcome these challenges are effective resource allocation and user training. Overall, the web-based outpatient registration information system can be an effective solution to improve service quality at RSUD X.

Pending claims in Indonesia’s National Health Insurance (JKN) system pose a significant challenge, affecting hospital cash flow and administrative efficiency. A high rate of pending claims is often caused by incomplete documentation, misfiled medical records, and delays in verification processes. Optimizing manual administrative procedures may provide a solution to this issue. This study aims to evaluate the effectiveness of a standardized manual administration model in reducing pending claims in a hospital setting. A quasi-experimental pretest-posttest design without a control group was employed. Data were collected from a referral hospital in Indonesia from July to September 2024. A total of 138 inpatient claims were selected using simple random sampling. The intervention involved implementing a standardized manual administration system in August and September. Statistical analysis was conducted using Fisher’s Exact Test with a significance level of p < 0.05. The implementation of the standardized manual administration model significantly reduced pending claims from 70.3% (97/138) in July (pre-intervention) to 36.2% (50/138) in August and further to 11.6% (16/138) in September (post-intervention) (p = 0.000 and p = 0.003, respectively). Additionally, improvements were observed in medical record completeness, supporting examination documentation, and administrative accuracy. A standardized manual administration system effectively decreases pending claims in JKN by improving documentation and claim verification processes. Further research is needed to explore the long-term sustainability of this model and the potential benefits of digitalization.  

Leprosy is a chronic infectious disease caused by the bacterium Mycobacterium leprae. It is a neglected tropical disease, still found in more than 120 countries, with more than 200,000 new cases reported each year.. The purpose of this research is to characterize leprosy patients in Lhokseumawe City and to describe the Multi Drug Therapy therapy. Information about the therapy, including the kind of leprosy, age, gender, employment, and the precise period of treatment, is evaluated in this research. Instruments for measurement were derived using data collected from medical records in this cross-sectional observational investigation. A whole sampling population was used in the sampling procedure, with 42 respondents making up the sample. Based on these findings, MB leprosy is the most frequent form of the disease (90.5% of cases), men make up the majority (64.3%) of leprosy patients, and the majority of leprosy patients are adults (88.1%). Results from the MDT treatment protocol indicated that 76.2% of patients were considered to have finished therapy (RFT), with the biggest occupational category being patients who did not work, accounting for 50% of the total. It is imperative that leprosy officers work to promote health promotion in order to raise awareness, decrease negative stigma, and speed up the discovery of leprosy cases

Hypertension is a chronic disease that often attacks the elderly and can cause serious complications, including stroke and heart disease. This study aims to evaluate the use of antihypertensives and analyze drug interactions based on severity in hospitalized patients at RSU Royal Prima Marelan. The research method is descriptive retrospective of patient medical records in 2024. The results showed that the majority of patients were women (62.5%) aged 60–74 years (50%). The use of a combination of two antihypertensive drugs was most commonly found (40%), with the combination of amlodipine and candesartan being the most frequently used. The severity of the most drug interactions was in the moderate category (82.35%), followed by major (10.50%) and minor (7.14%). The most significant interactions occurred in the combination of candesartan and spironolactone (major), and amlodipine and bisoprolol (moderate).    

The use of drugs for hyperuricemia and gout arthritis is given for conditions that cause higher purine metabolism in the body. This study was conducted at RSU Royal Prima Marelan to determine the pattern of drug use for hyperuricemia and gout arthritis due to inflammation caused by uric acid deposits in the joints. Data collection in this study was carried out retrospectively by collecting medical records of patients with hyperuricemia and gout arthritis. The descriptive method used in this study was a cross-sectional plan. Qualitative descriptive analysis was applied to the data. Tables or narratives were used to present the data in this study. The results showed that 30 patients out of 50 were male and 20 were female. The results of the evaluation of the rationality of drug use for hyperuricemia and gout arthritis showed that patients who were given several versions of drugs with the xanthine oxidase inhibitor group 64% were allopurinol with patients with the most appropriate indications, the right patient, and the right dose of 96%.

The implementation of Electronic Medical Records (EMR) in healthcare institutions aims to improve the efficiency, accuracy, and accessibility of medical data. RSUD Weda, a regional hospital in Indonesia, has adopted an EMR system in its outpatient services to replace conventional manual processes. However, this transition has faced several challenges, including inadequate training, unstable network infrastructure, and inconsistent adherence to Standard Operating Procedures (SOPs). This study aims to evaluate the performance of the EMR implementation using a qualitative descriptive method based on the 5M framework—Man, Material, Machine, Method, and Money. Data were collected through interviews, direct observation, and document analysis involving stakeholders such as medical staff, administrators, and IT personnel. The findings indicate that while users acknowledge improvements in data accuracy and accessibility, key issues remain, particularly in training quality, infrastructure readiness, and system reliability. The study also observed gradual improvements in SOP compliance and reduced system failures over time. These results suggest that successful EMR adoption requires a balance of technical infrastructure, human resource readiness, financial support, and continuous system monitoring. The use of the 5M framework proved effective in identifying multidimensional challenges and offering holistic insights into the implementation process. This study contributes to the broader literature on EMR evaluation by providing contextualized evidence from a district-level hospital and offers practical recommendations for enhancing EMR system performance in similar healthcare settings.    

process standardization, and system optimization. The study concludes that the HOT-FIT model is This study evaluates the performance of the outpatient registration information system at RSUD Komodo using the Human-Organization-Technology Fit (HOT-FIT) framework. Hospital Information Systems, particularly in the outpatient registration process, are crucial for supporting service efficiency and data accuracy. However, RSUD Komodo has experienced several challenges in the implementation of its SIMRS module, including system slowdowns, sudden monitor failures, and unstable internet connectivity during service hours. These issues hinder operational effectiveness and risk compromising service quality. The objective of this research is to assess system performance comprehensively across human, organizational, and technological dimensions. A qualitative descriptive design was employed, involving in-depth interviews with five key informants: registration staff, IT personnel, coder, head of the medical records unit, and head of the casemix team. The findings show that in the human dimension, users lacked sufficient training and adaptation strategies. In the organizational aspect, weak coordination and the absence of standardized procedures were identified. In the technology dimension, hardware malfunctions and slow system performance significantly disrupted services. These interconnected issues reveal the need for capacity buildingan effective tool for evaluating hospital information systems, offering a structured approach to identifying and resolving performance gaps in outpatient service modules.

Knowledge is the result of the process of understanding and recognizing something obtained through sensing an object. Beta-lactam antibiotics are a type of broad-spectrum antibiotic commonly used to treat bacterial infections, but their use still has the potential to cause side effects in the form of Adverse Drug Reactions (ADRs). This study aims to assess the level of patient knowledge regarding ADRs due to the use of beta-lactam antibiotics at Bendan Pekalongan Regional Hospital in 2024. This study used a prospective correlation design with a non-experimental approach. A total of 29 outpatients taking beta-lactam antibiotics were sampled, selected using a purposive sampling technique. Data were collected through questionnaires, medical records, and analyzed descriptively using Microsoft Excel. The results showed that 41% of respondents had low knowledge regarding ADRs, 28% had sufficient knowledge, and 31% had good knowledge. These findings indicate the need for more intensive education regarding the risks of ADRs in order to improve the safety of antibiotic use.

Health service management has an important role in managing resources effectively and efficiently, dealing with the dynamics of community needs, and ensuring quality health services through a systematic and humanistic approach. However, there are still shortcomings in the availability of adequate resources and managerial skills of implementing officers in service units that do not meet the standards. This study aims to analyze the direct impact of health management on accessibility, quality, effectiveness, and policy-making in health services.This study uses a literature review method with data sources obtained from Google Scholar, National Library e-Resources, and Garuda Portal. The research data was taken from 2015-2025. Based on the literature review, effective health management includes strategic planning, strengthening internal management, managing human resources, community involvement, and utilizing technology. The implementation of health management is proven to improve the competence of health workers, accelerate service processes, and increase patient satisfaction. In addition, good health management also encourages the expansion of health facility distribution, maintains the availability of drugs and medical devices, and improves the quality of infrastructure. However, there are challenges that need to be overcome, such as limited human resources and challenges in implementing Electronic Medical Records (EMR) in various healthcare facilities. The review shows that health management positively impacts accessibility, service quality, effectiveness, and evidence-based policymaking. Effective strategies include strategic planning, internal managemen human resource management, technology use, and community involvement, although challenges like limited human resources and Electronic Medical Record implementation remain

Informed consent is a fundamental legal document in medical practice, ensuring that patients provide informed approval before undergoing medical procedures. The completeness of this document is crucial for legal compliance and patient safety, as incomplete or improperly filled out consent forms can lead to legal disputes and compromise patient well-being. This study aims to evaluate the completeness of informed consent forms for general surgery patients, employing the 5M method (Man, Money, Method, Material, and Machine) to identify the factors contributing to form deficiencies. A quantitative descriptive approach was employed, with a sample of 265 forms selected using Slovin’s formula from a total of 711 forms collected between June and August 2023 at a hospital in Indonesia. The findings indicate that incomplete forms are primarily caused by human factors, such as a lack of medical personnel’s understanding of the informed consent process, procedural issues, including unclear standard operating procedures, and system limitations, such as partial integration of electronic medical records. The analysis of these factors reveals the significant impact of human error and procedural gaps on the completeness of informed consent documentation. To enhance the quality of documentation and ensure better compliance with medical regulations, this study recommends a series of improvements, including medical staff training, revision of standard operating procedures, and optimization of electronic medical record systems. Implementing these improvements is expected to strengthen compliance with medical regulations, enhance the documentation process, and contribute to better patient safety and legal protections in the healthcare setting.

The release of medical information is the process of disclosing or sharing information about a patient's health condition, medical history, or medical examination results with other parties. Due to the sensitive nature of the information contained in medical records, healthcare providers are obligated to ensure that all information is appropriately accountable. This study aims to explore the work activities of medical record officers and health information management in the process of releasing medical information to insurance parties at Tarakan Regional General Hospital (RSUD Tarakan). This research uses a descriptive method with a qualitative approach by explaining the results of interviews regarding the work activities of medical record officers and health information management in the process of releasing medical information to insurance parties. RSUD Tarakan already has standard operating procedures related to the release of medical information, both to insurance parties that cooperate and to those that do not cooperate. In the work activities of the officers, the stages of data collection for insurance types, the request flow stage, data collection stage, data processing stage, and data presentation stage involve the insurance services and fundraising departments in the release process for cooperating insurance parties. Meanwhile, the medical records department and the information department are only involved in the release of medical information to non-cooperating insurance parties. The challenges in releasing medical information to non-cooperating insurance parties include the lack of requirements provided by patients, as they are often unaware of the necessary documents and the process for requesting the release of medical information, which can cause delays in the process.

Hypertension in pregnant women is a serious health issue that contributes to the high maternal and fetal mortality rates. This condition can be influenced by various factors, including family history and physical activity. This study aims to analyze the relationship between family history and physical activity with the incidence of hypertension in pregnant women in the working area of Puskesmas Asera, North Konawe Regency. This research employs an observational analytic design with a case-control approach. The respondents consist of 38 pregnant women selected using the total sampling technique. Data were collected through questionnaires and medical records and then analyzed using the Chi-Square test. The results indicate a significant relationship between family history of hypertension (p=0.000) and physical activity (p=0.021) with the incidence of hypertension in pregnant women. This study concludes that hereditary factors and low physical activity increase the risk of hypertension during pregnancy. Therefore, preventive efforts are needed through health education, increased physical activity, and routine monitoring during pregnancy at healthcare facilities. With these measures, it is expected that the incidence of hypertension in pregnant women can be reduced, ensuring better maternal and fetal health.

Admission services in the emergency department (IGD) are an important part of hospital operations that require effective management to support health services. Optimal medical record management requires human resource planning according to actual workload. This research was conducted to analyze the need for admission registration at the Duren Sawit Regional Special Hospital (RSKD) with a quantitative approach using descriptive methods. The research results show that RSKD Duren Sawit has Standard Operational Procedures (SPO) which refer to Minister of Health Regulation No. 33 of 2015 in planning health human resource needs (HRK). Health workload analysis indicates that the ideal requirement is seven admissions officers, while currently only five officers are available, so there is a shortage of two officers. Factors that influence the workload of admission registration include: Man, namely the limited number of officers in the medical records unit, Machine, namely the BPJS server down and power outages, Material, namely the mixed admissions work room with the cashier so the medical record files are still in one room, Method, namely the HR application process at RSKD Duren Sawit found no obstacles, Money, namely there is no budget planning for additional officers in the medical records unit.

Thalassemia is an inherited blood disorder characterized by a deficiency of globin chain products in hemoglobin which results in low Hb levels. Blood transfusion is a treatment used in thalassemia patients. The purpose of this study was to determine the level of blood transfusion compliance in pediatric thalassemia patients at Cut Meutia General Hospital, North Aceh. The research method used a descriptive observational design, with 95 respondents and data collection using medical records and questionnaires. The results showed that 43.2% of respondents were predominantly early adolescents, 54.7% of respondents were predominantly male, 42.1% of respondents were predominantly blood type O, 58.9% of respondents had hemoglobin levels ≥7 g/dl, 87.4% of respondents had a blood transfusion frequency of 2-4 weeks. 53.7% of respondents had high compliance. Based on this, it can be concluded that the level of blood transfusion compliance in pediatric thalassemia patients at Cut Meutia General Hospital, North Aceh, mostly had high compliance.

The rapid development of health technology has significantly contributed to healthcare services. Technologies such as Electronic Medical Records (EMR), telemedicine, and Artificial Intelligence (AI) have improved healthcare accessibility. However, these advancements also present legal challenges, particularly regarding patient data protection and liability for medical errors (malpractice). Patients have the right to data privacy, and data breaches can have serious consequences. In Indonesia, regulations such as the Ministry of Health Regulation No. 24 of 2022 on Medical Records have been implemented to strengthen patient data security. However, legal gaps still exist, particularly concerning the responsibility of third-party technology providers. Additionally, the application of technology increases the risk of malpractice, especially in the use of AI and telemedicine, where diagnostic errors can occur. Current regulations, including Law No. 17 of 2023 on Medical Health, do not fully address liability for errors involving technology. Therefore, stronger legal certainty and more comprehensive regulations are needed to keep pace with the rapid development of health technologies.

Electronic Health Records (EHRs) have become an important component in the digital transformation of the healthcare system in Indonesia. However, EHR implementation in many health facilities in Indonesia is still fragmentary and not fully integrated. The main challenges in integrating health data into the national health system are issues of interoperability, data security, and inter-institutional coordination. This study aims to identify and analyze the main challenges in integrating health data from various EHR systems into Indonesia's national health system and its impact on the quality of health services, operational efficiency, and data security. The research method used was a descriptive qualitative approach, which combined literature study and in-depth interviews with experts in the field of health information technology and health policy. A literature study was conducted to identify technical, operational, and policy challenges faced in EHR implementation in Indonesia. Expert interviews were used to validate the findings obtained from the literature and provide additional insights into the local context. Thematic analysis techniques were used to organize and interpret the data. The results showed that the lack of common data standards is a major obstacle in the integration of EHR systems in Indonesia.A total of 45% of healthcare facilities adopt HL7 standards, 30% adopt FHIR, and 25% use proprietary systems, leading to the inability to efficiently share data between institutions. In addition, data security issues are also a major concern, with many healthcare facilities yet to implement adequate security protocols. Limited coordination between health institutions also hinders wider integration. Nonetheless, EHR integration has the potential to improve operational efficiency, with up to 25% reduction in administrative time in institutions that have integrated their systems.

The Electronic Medical Record Information System (RME) is an information technology solution used to manage patient medical record data digitally, replacing manual recording systems that are prone to errors and data loss. This report discusses the design and implementation of the Electronic Medical Record Information System (RME) at the Community Health Center, which aims to increase efficiency, accuracy and security in managing patient medical records. This system includes recording medical data, treatment history, diagnosis, drug prescriptions, as well as integration with other health service systems. With RME, the medical service process at the Community Health Center is expected to be faster, more transparent and organized. This research uses a web-based system development method with database-based programming, which allows medical record data to be managed centrally and easily accessed by authorized medical personnel. The results of implementing this system show a significant increase in speed of service as well as a reduction in administrative and medical errors.