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Background: By 2022 it will be found that 50% of the 3000 hospitals in Indonesia will have implemented electronic medical records. Of this percentage, only 16% have properly maintained electronic medical records. One of them is PKU  Muhammadiyah  Karanganyar Hospital implementing Electronic Medical Records (RME) in 2023  and it has only been fully implemented in the outpatient polyclinic section. For inpatient treatment, PKU  Muhammadiyah Hospital still uses manual. The objective of the research: to determine the level of user satisfaction with the implementation of Electronic Medical Records (RME) at PKU  Muhammadiyah  Karanganyar Hospital. Method: This type of research is quantitative descriptive using a cross-sectional approach. Results: the level of satisfaction of Electronic Medical Record (RME) users was 51.2% of respondents who felt satisfied seen in the 5 dimensions of  EUCS (End User Computing Satisfaction). The results obtained were that respondents felt satisfied (score 3.26) that the content was included in the category satisfied (3.41), accuracy (accuracy) is in the satisfied category (3.22), format (display) is in the satisfied category (3.16), ease of use is in the satisfied category (3.24 ), and timeless (punctuality) are in the satisfied category (3.27). Conclusion: the electronic medical record (RME) at PKU  Muhammadiyah  Karanganyar Hospital is running well and meets user expectations, especially in 5 aspects, namely content, accuracy, format, ease of use, and timeless.  

Quality of life is very important assessment in evaluating a person’s perception of the disease they have. Cancer stage characteristics and the type of therapy given to baldder cancer patients can affect the overall quality of life. This study aims to see the relationship of the stage of cancer and the type of therapy given with the quality of life. The type of this research is an analytical study with a cross sectional design. Sampling was done by consecutive sampling technique. The research took place from August 2021–March 2022 at RSUP Dr. M. Djamil Padang with a total sample of 64 people. The research instrument used was the EORTC QLQ-C30 questionnaire and medical records of patients with bladder cancer. Bladder cancer most often occurs in people with the age of >45 years old and male sex. The most found stage in bladder cancer is stage II and the most frequently implemented therapy is TURBT. Cancer stage and the type of therapy used had a statistically significant relationship with the quality of life of bladder people with the age of >45 years old and male sex. The most found stage in bladder cancer is stage II and the most frequently implemented therapy is TURBT. Cancer stage and the type of therapy used had a statistically significant relationship with the quality of life of bladder cancer patients (p=0.01; p=0.04). There is a significant relationship of the cancer stage and type of therapy given with the quality of life of bladder cancer patients.

Prompt return of patient medical records is an important step in the health records processing workflow. Speed is the key to meeting quality processing standards. The hospital sets a deadline for returning medical records within 2x24 hours after the patient is discharged. Delays can be caused by various factors, which are classified under the 5M management elements: man, materials, machines, methods, and money. The aim of this research is to identify aspects that are the root of the problem in delays in the process of returning medical records to the hospital. The methodology used is a literature review, with analysis of 17 journal articles from the Google Scholar database. The study results showed that human factors such as staff shortages, incomplete doctor signatures, and inadequate staff educational qualifications were the main causes of delays. Material factors often result in incomplete documents. The machine factor is related to the significant distance between the inpatient department and the medical records department. Meanwhile, the method factor, namely SPO socialization has not been carried out and the implementation of job descriptions has not been maximized.

Dyspepsia is a disease of the digestive tract that is not contagious but is common among people in the world. Dyspepsia can be experienced by various age ranges, gender. According to research, the risk factor for organic dyspepsia is age > 50 years. This is thought to be related to the increasing prevalence of chronic diseases in old age. Dyspepsia has an impact on quality of life because the natural course of dyspepsia is chronic and often recurs. This research is a quantitative research using a descriptive analytic research design. The sample in this study were dyspepsia patients at Nurdin Hamzah General Hospital, East Tanjung Jabung Regency, totaling 80 people. The sampling technique used in this research is purposive sampling technique. This research was conducted at the Nurdin Hamzah General Hospital, East Tanjung Jabung Regency, in 26 June – 04 July 2023, then the data will be obtained by looking at the medical records of dyspepsia patients at the Nurdin Hamzah General Hospital, East Tanjung Jabung Regency. Data analysis was performed univariately. Based on the results of the study, it was found that patients aged > 65 years (elderly) were 20 respondents (25%) with dyspepsia, some of the dyspepsia patients were female, namely 55 respondents (68.8%), with working status, namely 44 respondents (55.0%) ), patients had a history of co-morbidities, namely 47 respondents (58.8%) and most dyspepsia patients had a history of drug use, namely 43 respondents (53.8%). It is recommended as input to the hospital to find out the problem about the description of the characteristics of dyspepsia patients

Hospitals establish Minimum Service Standards (SPM) for medical records, specifically emphasizing the requirement for completeness in filling out medical records within 24 hours of service completion and achieving a 100% completeness standard for informed consent after receiving clear information. This study aims to develop a compliance model for Professional Care Providers (PPA) in filling out medical records, incorporating motivation as an intervening variable based on knowledge and attitude variables among inpatients at Cilincing Hospital. The sampling method employed is saturated sampling, with a total sample size of approximately 82 respondents. Path Analysis is utilized for data analysis, employing AMOS software. The research findings indicate a significant influence of knowledge, attitudes, and motivation of Professional Care Providers (PPA) on the overall compliance with the completeness of medical record filling, both collectively and individually. Moreover, the study reveals a significant impact of knowledge and attitudes on the motivation of Professional Caregivers (PPA). Additionally, motivation, acting as an intervening variable, demonstrates its ability to mediate the influence of knowledge and attitudes of Professional Care Providers (PPA) on compliance with the completeness of medical record filling. 

Grha Kedoya Hospital in West Jakarta faces significant challenges in document management, including medical records, financial reports, and administrative documents. This study aims to analyze the document storage system in the Secretariat Unit of Grha Kedoya Hospital using the User Acceptance Testing (UAT) method. The results show that the security, functional, and non-functional aspects of the document storage system are rated very well by respondents, with average scores of 80.4%, 81.4%, and 76.4% respectively. Despite challenges in transitioning to a digital system such as staff adaptation and infrastructure investment, the majority of respondents support this change to enhance efficiency and security. The UAT method proves effective in identifying the system's strengths and weaknesses, providing constructive feedback for improvement.

Doctors have a legal responsibility to ensure that patient medical records are complete and accurate. A legal analysis of the doctor's responsibility for the completeness of patient medical records in order to fulfill patient rights in hospitals is an important study to ensure that patient rights are fulfilled in accordance with the standards set by applicable laws and regulations. A comprehensive analysis of the doctor's responsibility and the importance of complete medical records is expected to create a better health care system that respects and fulfills patient rights optimally. This study uses a normative legal method. The conclusions of this study are: 1) The doctor's legal responsibility for fulfilling the patient's right to obtain complete Medical Records as a form of the patient's right to information in health services. This right is protected and regulated in a number of legal regulations. Fulfillment of the method of obtaining the contents of Medical Records to patients must also pay attention to and follow the procedures as stipulated in the laws and regulations. 2) The legal consequences of the doctor's legal responsibility if they violate the fulfillment of the patient's right to complete Medical Records, including: 1) criminal sanctions, namely imprisonment for a maximum of 1 (one) year and a maximum fine of Rp. 50,000,000.00 (fifty million rupiah) (Article 79 point b of the Medical Practice Law Law No. 29 of 2004), 2) civil sanctions in the form of compensation by the Hospital or the doctor to the patient (Article 1365 of the Civil Code) and 3) administrative sanctions in the form of written warnings and/or recommendations for revocation or revocation of accreditation status. (Minister of Health Regulation 24 of 2022 concerning Medical Records).

Intrauterine device is one of the long-acting contraceptives made of plastic wrapped in copper that is inserted into the uterus through the vagina to prevent pregnancy. IUD is one of the contraceptives that has high effectiveness. IUD has side effects, namely menstrual disorders, spotting, spulsion, vaginal discharge. to determine the relationship between the use of IUD contraceptives with menstrual disorders. type of research correlative with cross sectional design. This research was conducted at PKU 'Aisyiyah Boyolali Hospital in December 2023. The subjects of this study were 58 IUD birth control acceptors at PKU 'Aisyiyah Boyolali Hospital during April – November. The sampling technique uses purposive sampling. The measuring instrument uses medical records and questionnaires. The data analysis method uses the chi-square test.  the majority aged 31-40 years are 73.1%, have a high school education of 43.6%, the majority use a Nova-T IUD of 58.9% and have menstrual disorders as much as 57.1%. The results of the chi-suare  test obtained results of nilia p-value 0.000 <0.05, then Ha is accepted so that there is a relationship between the use of contraceptives and menstrual disorders. There is a relationship between the use of intrauterine devices and menstrual disorders at PKU 'Aisyiyah Boyolali Hospital

Medical tourism is a medical activity that is included with tourism activities. Currently, medical tourism has become a promising trend for Indonesia. This is supported by the potential of its natural beauty. However, there are challenges related to medical tourism itself. Thus, the problem of this research is how to analyze the law regarding the opportunities and challenges of medical tourism in Indonesia. The aim of this research is to determine the legal analysis of medical tourism in Indonesia. This research uses a normative juridical approach, qualitative descriptive research specifications, library study data collection methods and qualitative data analysis methods. The results of this research are the enactment of Minister of Health Regulation no. 76 of 2015 concerning Medical Tourism Services, the health industry in Indonesia has a legal umbrella that can provide opportunities for Indonesia in competitions for providing medical tourism. However, the absence of clear and specific legal regulations regarding medical tourism guides, as well as the weak legal framework for protecting personal data regarding patient medical records, especially for foreign patient data, can be a challenge for medical tourism. Thus, the government needs to overcome these challenges and increase existing opportunities.  

Nowadays information technology is developing very rapidly in the health sector. As technology advances, the use of medical records has begun to shift from conventional or paper-based to digital. Electronic medical records (EMR) are an important part of health services. Electronic medical records are electronic information created by health care providers based on patient conditions, forwarded and sent to other departments for consultation and further examination and received and stored in digital form and can be viewed at any time if needed. Electronic medical records are very useful for healthcare organizations, healthcare professionals as well as patients. The purpose of this study was to analyze the implementation of electronic medical records and legal studies. This study used normative juridical research methods. This study had a specificity, namely descriptive-analytic where this study sought to analyze legal issues and also the legal system, that it could be understood and then conclusions could be drawn. The results showed that the implementation of electronic medical records, namely first, the implementation of electronic medical records could increase the accuracy and security of data. Second, the implementation of electronic medical records could increase efficiency and productivity. Third, the implementation of electronic medical records could provide better service to patients. The legal basis for implementing electronic medical records was contained in the Regulation of the Minister of Health Number 269/MENKES/PER/III/2008 concerning Medical Records where in Article 2 Paragraph (2) it was explained that "Medical records must be written, complete and clear or electronic". ITE Law Number 19 of 2016 did not regulate how electronic medical records were issued. Electronic medical records as a form of medical document must comply with applicable legal requirements, such as the right to privacy, confidentiality, accuracy and data security. It was hoped that legal certainty in the implementation of electronic medical records could help improve and improve health services.

In line with its development, Electronic Medical Records have become the heart of information in the Hospital Management Information System (SIMRS), which is the main application in a basic data management system that collects various sources of medical data, plus other features such as administration, billing and documentation services. medical. However, electronic medical records certainly raise new problems in the area of ​​patient confidentiality and privacy. If a patient's medical data falls into the hands of an unauthorized person, legal problems and responsibilities could arise for the hospital and doctor who handles the patient, therefore standards for making and storing medical records that have been made conventionally or on paper must also be applied to Electronic medical records must be made secure and patient data must be strictly guarded by the hospital, meaning that no information can be opened without the patient's permission, which means that all patient medical information data can only be accessed by interested people. These people are also not allowed to transfer this information to other people. The implementation of Electronic Medical Records in Health Facilities is carried out by a separate work unit or adjusted to the needs and capabilities of each Health Fascily. In terms of the scale of health services, health facilities are very different from hospitals, especially those in remote areas. In fact, not all hospitals are ready to implement a medical history recording system, the total use of telemedicine applications which has increased up to six times during the 2022 COVID-19 pandemic in Indonesia.    

Teledentistry is a relatively new combination of telecommunications technology and dental care. It has its roots in telemedicine, which involves the use of communications and information technology to provide health services across geographic distances. Teledentistry faces several challenges, including limited internet access and inadequate infrastructure in remote areas, concerns about the confidentiality of electronic medical records, and incomplete regulations regarding teledentistry in the current law. The problems raised in this research are the obstacles faced by teledentistry practitioners in Indonesia, including factors that hinder their ability to manage medical risks and legal protection for teledentistry practitioners who face medical risks such as drug allergies. Legal protection for dentists in the field of teledentistry when facing medical risks, such as allergies to electronically prescribed medications. Dentists must obtain legal guarantees and certainty in providing health services to their patients. The conclusion of this study is that in teledentistry consultation services, medical risks such as drug allergies, which are unpredictable reactions of the patient's body, cannot be predicted. Medical risk is not a form of medical malpractice. Because, in medical risks, one of the elements in articles 338 and 359 of the Criminal Code cannot be fulfilled, namely the element of negligence.

Health service facilities have the duty and obligation to protect the confidentiality of information contained in medical record files and must not disclose or provide this information to unauthorized people or institutions. The aim of this research is to determine legal protection for the confidentiality of patient data between conventional and electronic medical records. The research method used is normative juridical. The research results show that legal protection can be grouped into two, namely preventive and repressive legal protection. Preventive legal protection or prevention of violations related to medical records can be carried out by maintaining the confidentiality of medical records, maintaining medical record storage, and maintaining procedures for the release of health information. Meanwhile, repressive legal protection can be carried out by taking responsibility for violations that have been committed in the form of criminal, civil and administrative sanctions.

This study aims to analyse the workload of doctors at Ubhara Jaya Primary Clinic in order to improve the efficiency and quality of medical services. Effective human resource management, particularly in managing doctors' workload, is essential to provide fast, precise, and quality health services. This study uses the Full Time Equivalent (FTE) method to measure and analyse doctor workload. Interviews and direct observation were used to get primary data, while secondary data was collected from relevant documents such as doctors' work schedules, monthly reports, and medical records. The research method used is descriptive with a quantitative approach, as well as literature review as a theoretical basis. The overall results of the various activities carried out by doctors at the Ubhara Jaya Primary Clinic show that the FTE index value is below the normal limit, these results indicate the need for additional workload and do not require additional labour for each activity performed.

Completeness in filling of medical record files by doctors will be able to facilitate other health workers in providing action or treatment to patients, and can be used as a source of data in the Medical Record section in data management and reports that will be used as useful information for hospital management in determining evaluation and development of health services. At this time at RS X based on the Quality of Medical Records, the completeness of filling in the Medical Records of inpatients for the period January –Desember 2023  is still 59%. The purpose of this study was to analyze the compliance analysis of doctors filling out patients Medical Records at the inpatient installation of RS X Jakarta in 2023.The study was conducted with a cross sectional design, using a sample of 60 specialist doctors at RS X. Data were analyzed by Chi Square. Sources of Data This research is primary data collected by the method of distributing questionnaires as a research instrument.The results of the study concluded that there was a significant relationship between age, gender, knowledge, attitudes and motivation of doctors with compliance in filling out medical records with p-value ˂ 0.05. There is no significant relationship between tenure and compliance in filling out medical records with p-value = 0.452 ˃ 0.05. The most dominant relationship in physician compliance in filling out medical records is Doctor's Knowledge and Motivation with p-value = 0.000 ˂ 0.05. Dominance of knowledge and motivation of doctors in filling out medical records. The suggestion is that the knowledge and motivation of doctors really need to be a concern and the hospital management should consider things related to improving the quality of doctors in filling out medical records. Knowledge improvement in regulatory updates, SOPs and procedures for filling out medical records is very important. The use of electronic medical records can provide great benefits for health services such as hospitals.  

The COVID-19 pandemic has significantly impacted elderly health, requiring regular medical check-ups to monitor their condition. This study examines the health examinations of the elderly at Posyandu Ngudi Waras, Semanggi RW XII, Surakarta, during the pandemic. The research aims to assess the frequency of health check-ups, key health indicators such as blood pressure, oxygen saturation, blood sugar levels, and body mass index, as well as the challenges faced in providing healthcare services for the elderly. Using a descriptive quantitative approach, data were collected through medical records and interviews with healthcare providers and elderly participants. The results indicate that despite pandemic-related restrictions, routine health monitoring continued with adjustments to health protocols. The findings highlight the importance of community-based health services in ensuring the well-being of the elderly, particularly during health crises. Strengthening health programs for the elderly, enhancing accessibility, and improving awareness of preventive healthcare are essential for maintaining their quality of life.

Since the emergence of the COVID-19 pandemic, the transformation of the health sector in Indonesia has taken place with the beginning of the era of digitization of health services, one of which is the digitization of the implementation of electronic medical records through the Regulation of the Indonesian Minister of Health (PMK) No. 24 of 2022 on Medical Records. Through this regulation, the Government provides freedom for health care facilities to choose the system to be used, which can be a system developed independently, a system developed by the Ministry of Health, or can also collaborate with vendors providing information systems or partner systems for short. However, there is no detailed description of the liability for leakage of electronic medical record data whose system comes from a partner system, so that clear boundaries are needed regarding this matter. This research aims to explore the legal standing of electronic medical record system providers or system partners and the legal liability provided in the event of an electronic medical record data leak. The result of this research is the position of the partner system as a form of PSE in accordance with the provisions of Government Regulation Number 71 of 2019 on the Implementation of Electronic Systems and Transactions and the legal liability of the partner system for leakage of electronic medical record data is as a Controller of Personal Data based on Law Number 27 of 2022 concerning Personal Data Protection.

Introduction: Mother's milk (ASI) is a very good nutritional intake for newborn babies. Natural breast milk produced by mothers has important nutrients for babies. Breast milk contains various microbial materials. Nutrition for mothers who are breastfeeding must be given optimally. Oxytocin massage is a non-pharmacological technique that functions to overcome substandard breast milk production. Objective: This study aims to determine the effect of breastfeeding education on breast milk production. Method: This research uses a descriptive observational method using a case study method approach. The subject used was a postpartum mother patient with breast milk production problems in the NICU room at Dr. Tjitrowardojo Hospital, Puroworejo. Data collection was carried out by interviewing Mrs. V and also looked at the medical records in the PICU/NICU room using the neonate assessment format developed by the UMY FKIK Nurse Professional Education. Results: After being given intervention for 5 days, there was an effect of breastfeeding education on breast milk production. Conclusion: Breastfeeding education can influence breast milk production.

The rapid development of information technology has penetrated into various sectors of life, including in the health sector, which has also had an impact on the development of computer-based medical record systems. The purpose of this study was to determine the implementation of Electronic Medical Records at the Internal Medicine Clinic at Kembangan Hospital. The research method uses descriptive methods with qualitative analysis on 10 informants by means of observation and interviews which will provide an overview and see directly a situation when the use of electronic medical records is carried out. The results showed that the hospital already had an SOP for filling in electronic medical records, which was not implemented according to what the officers did. The use of Electronic Medical Records, especially in the Internal Medicine Polyclinic, has gone well. Constraints from 5M Factor, namely Man, there are still registration officers who are incomplete or incorrect in filling in patient identity data, PPA (Professional Caring Provider) is incomplete in filling in patient diagnoses, Internet network material is sometimes slow, and the server is sometimes down, user complaints include display is less efficient, when filling. It is suggested to the Medical Record Unit, IT team and hospital management to evaluate the SOP, revise and socialize it in order to reduce the human error factor. Kembangan Hospital needs to improve the appearance of SIMRS Khanza to make it more attractive so as to increase the enthusiasm of the officers in inputting medical record data at SIMRS. Kembangan Hospital should improve network quality in the hospital environment to improve the performance of SIMRS.

Medical record is a document that contains patient identity data, treatment, examination, action, and other services that have been given to patients. In order for medical records to be maintained, supervision is needed in medical records. The purpose of this study was to find out how the oversight of the medical record alignment system with the Standard Operating Procedures at the Jakarta Islamic Hospital Cempaka Putih. This research method uses a descriptive method with qualitative analysis, conducting observations and interviews that aim to provide an overview and see directly a state of the supervision process during the alignment of medical records in the filing room of the Jakarta Islamic Hospital Cempaka Putih. This research was conducted in a storage room with 5 informants. The results of the study showed that the supervisory process was aligned with the supervisory element, namely determining the size of the implementation, there was a deficiency, namely there was no mention of tasks in the job description in controlling medical records. In measuring the actual implementation, there are inappropriate implementations such as misfiles and there are several tracers that are still hanging. In measuring behavior, officers do not yet have definite standards or tools to measure officer performance behavior. Obstacles in the alignment of medical records through the 5M factor, namely, the lack of number of officers in the filing room, the occurrence of misfiles and staff errors in writing unclear numbers. Materials namely, there are a lot of maps that are too thick. Machines, that is, there are still many tracers hanging on storage racks whose time limit has passed the stipulation. Methods, that is, the Hospital does not yet have an SOP for alignment supervision and there is only a Medical Record alignment system in the SOP for storing and returning Medical Records.