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Background: Schizophrenia is a serious chronic mental disorder that can affect thinking, perception, feelings, and behavior. Patients with undifferentiated schizophrenia are at risk of experiencing the nursing problem of risk of violent behavior (RPK) due to their inability to control emotions and anger. Based on data from the medical records of RSJD dr. Amino Gondohutomo, Central Java Province, from August to October 2025, the risk of violent behavior was the highest nursing diagnosis in the Gatotkaca Ward, reaching 56.5%–77% of all inpatients. Objective: To perform nursing care on Tn. K with the main problem of risk of violent behavior due to undifferentiated schizophrenia at RSJD dr. Amino Gondohutomo, Central Java Province. Methods: This study used a descriptive method with a nursing process approach. Data collection was carried out through interviews, observation, documentation studies, and literature review. Nursing care was provided from November 18 to 22, 2025. Results: Assessment findings on Tn. K (19 years old) with undifferentiated schizophrenia and a history of physical abuse, parental rejection, and family violence revealed four nursing problems: risk of violent behavior (core problem), sensory perceptual disorder: auditory and visual hallucinations, self-concept disorder: low self-esteem, and self-care deficit. Implementation was carried out through nursing strategies (SP) 1 to 4 for risk of violent behavior (physical, medication, verbal, and spiritual control), SP 1 and SP 3 for self-care deficit, and SP 1 to SP 2 for sensory perceptual disorder: hallucinations. All implementation stages were optimally achieved. Conclusion: Nursing evaluation showed that the client was able to achieve cognitive, affective, and psychomotor goals in all implemented SPs. Collaboration with ward nurses was carried out to continue SP 3 and SP 4 for hallucinations and the entire low self-esteem intervention due to time constraints.

Diabetes Mellitus Type II is a chronic metabolic disease characterized by elevated blood glucose levels due to insulin resistance and impaired insulin secretion. Globally, the number of people with diabetes in 2024 is estimated to reach 800 million, with more than 95% being Type II Diabetes Mellitus. At RSUD Prof. M. Yamin, SH Pariaman in 2025, there were 189 recorded cases of Type II Diabetes Mellitus without complications. The purpose of this scientific paper is to provide nursing care to a patient with Type II Diabetes Mellitus in the Internal Medicine Ward of RSUD Prof. M. Yamin, SH Pariaman. The method used is a case study with a nursing process approach, including observation, interviews, physical examination, and data collection from medical records. This study was conducted in the internal ward for 5 days, from February 6, 2026 to February 10, 2026, with the subject Mrs. N. The assessment results identified nine nursing problems: unstable blood glucose levels, acute pain, impaired skin/tissue integrity, ineffective peripheral perfusion, impaired physical mobility, sleep pattern disturbance, fatigue, risk of infection, and risk of nutritional deficit. The evaluation after 5 days of nursing care showed that five diagnoses were resolved, namely unstable blood glucose levels, ineffective peripheral perfusion, fatigue, risk of infection, and risk of nutritional deficit. Meanwhile, the other four diagnoses were not fully resolved but showed improvement. It is expected that the patient and family will maintain adherence to a healthy lifestyle, therapy, diet, and regular follow-up in order to prevent complications.

The readiness of officers to carry out Electronic Medical Records (RME) needs to be measured using the Technology Readiness Index (TRI) method, which is an index used to measure the readiness of new technology users to achieve goals in daily life and work. This research aims to determine the readiness of Electronic Medical Record (RME) users using the Technology Readiness Index (TRI) case study at Daha Husada Regional Hospital. This is a descriptive research with an evaluation study where the research subjects are the head of medical records and 3 medical records officers in the inpatient registration section at Daha Husada Regional Hospital using a total saturated sampling technique. Data collection uses interview techniques. Data presentation is presented using narrative. The results of the research show that of the 4 variables used to measure the readiness of medical record users, medical record officers at Daha Husada Regional Hospital are ready to use medical records, even though they are ready there are still difficulties experienced and feelings of insecurity when using Electronic Medical Records (RME), namely Medical records can be accessed anywhere and are not yet integrated according to the user's wishes. Therefore, Daha Husada Regional Hospital should further tighten its electronic medical record data security system.

Supraventricular tachycardia (SVT) is one of the most common arrhythmias in the pediatric population, often resulting from re-entry mechanisms involving accessory pathways or dual atrioventricular nodal physiology. Although generally well tolerated in children with structurally normal hearts, its management can be challenging, particularly in recurrent or persistent cases. This study is a case report describing a pediatric patient with hemodynamically stable SVT treated at Dr. Wahidin Sudirohusodo Hospital. Data were collected retrospectively from medical records, including history taking, physical examination, and supporting investigations such as serial electrocardiography (ECG), laboratory tests, chest radiography, and transthoracic echocardiography. Management was conducted according to current clinical guidelines, including vagal maneuvers, pharmacological therapy with beta-blockers and antiarrhythmic agents (amiodarone), and monitoring of treatment response based on clinical evaluation and ECG, along with identification and treatment of underlying triggers. We report a case of a 10-year-old female presenting with suspected SVT and pericarditis, who experienced episodes of narrow QRS complex tachycardia that were successfully converted to sinus rhythm following amiodarone administration. Echocardiographic evaluation revealed mild to moderate tricuspid regurgitation with preserved ventricular function. Laboratory and radiological findings suggested an underlying inflammatory process, which was considered a triggering factor. This case highlights the importance of a comprehensive approach in the diagnosis and management of pediatric SVT, including addressing underlying conditions and ensuring continuous monitoring to prevent recurrence.

Turbinate hypertrophy is a condition characterized by abnormal enlargement of the nasal turbinate mucosa, which can lead to chronic nasal obstruction and decreased quality of life. This condition is associated with inflammatory processes in which eosinophils play a role as part of the immune response. This study aimed to determine the relationship between eosinophil levels and the degree of turbinate hypertrophy based on blood examination in hospitalized patients. This research used an observational analytic design with a cross-sectional approach involving 40 patients diagnosed with turbinate hypertrophy at Cut Meutia General Hospital, North Aceh. Data were obtained from medical records, including patient characteristics, eosinophil levels, and the degree of turbinate hypertrophy. The results showed that most patients were aged 17–25 years, predominantly female, and commonly had non-allergic underlying conditions. The majority of patients had normal eosinophil levels (80%), while most cases were classified as grade III turbinate hypertrophy (65%). Statistical analysis using Fisher’s Exact Test demonstrated no significant relationship between eosinophil levels and the degree of turbinate hypertrophy (p>0.05). These findings suggest that eosinophil levels may not be a reliable indicator in assessing the severity of turbinate hypertrophy, particularly in patients with non-allergic conditions. This study highlights the need to consider other contributing factors in the evaluation and management of turbinate hypertrophy to improve diagnostic accuracy and treatment outcomes.

Prescription service wait times are an indicator of pharmacy service quality that directly impacts patient satisfaction and the Hospital Minimum Service Standards (SPM). The Kraton Regional General Hospital in Pekalongan Regency has implemented an electronic prescribing system (e-prescribing) to improve efficiency and reduce prescribing errors. However, with prescription volumes reaching hundreds per day, periodic evaluation is necessary to ensure that services remain in compliance with standards. This study aims to evaluate the waiting time for electronic prescription services among outpatients at the Pharmacy Department of RSUD Kraton, Pekalongan Regency, and to compare it with the Ministry of Health’s standards. This is a descriptive observational study using a quantitative approach. The study sample consisted of 300 prescriptions (74 compounded prescriptions and 226 non-compounded prescriptions) selected via simple random sampling from medical records for the period August–October 2025. Research instruments included an observation sheet and an interview guide to support observational data. Data analysis was conducted descriptively to calculate the average service waiting time. The results showed that the average service time for non-compounded prescriptions was 7 minutes and 42 seconds, while for compounded prescriptions it reached 28 minutes and 11 seconds. All samples examined met the established waiting time standards, namely ≤30 minutes for non-compounded prescriptions and ≤60 minutes for compounded prescriptions, in accordance with Ministry of Health Regulation No. 4 of 2019 and Ministry of Health Decree No. 129/2008. The electronic prescription service at Kraton District General Hospital in Pekalongan Regency has been operating very efficiently and meets the Minimum Service Standards (SPM). The implementation of e-prescribing technology has significantly contributed to maintaining the speed and quality of pharmaceutical services on an ongoing basis.

The implementation of the Health Workload Analysis (ABK Kes) method reveals both strengths and weaknesses, particularly regarding the suboptimal execution of core tasks such as filing and distributing medical records. This study aims to compare the workload of health human resources (SDMK) between primary and advanced healthcare facilities—specifically Banyudono 1 Public Health Center and Indriati Boyolali Hospital—both of which have implemented hybrid medical record systems. Using primary data collected through interviews and observations and analyzed via the ABK Kes method, the results indicate a need for 10 additional staff members in the Casemix Unit at Indriati Boyolali Hospital and 2 additional medical record practitioners at Banyudono 1 Public Health Center. The Available Working Time (WKT) at the Public Health Center was set at 75,000 based on the Minister of PAN-RB Regulation No. 1 of 2020, whereas the Hospital used real-time calculations. While the Public Health Center aligns its policies with Ministry of Health Regulation No. 19 of 2020, the Hospital adjusts its staffing needs based on the ABK Kes results. Given that this method focuses primarily on quantity, future research and development (R&D) should integrate Lean Thinking for process analysis, ABK Kes for capacity, Queueing Theory for dynamic analysis, and NASA-TLX for psychological evaluation to provide a more holistic assessment of staffing needs.

Diabetes Mellitus is a chronic disease that requires early detection to prevent serious complications. This study aims to implement the Artificial Neural Network (ANN) algorithm with the Backpropagation method to predict the risk of diabetes. The dataset used is the Pima Indians Diabetes Dataset, consisting of 768 medical records with 8 feature attributes. This study employs the Multi-Layer Perceptron method with an architecture of 8 input neurons, two hidden layers, and 1 output neuron. Model evaluation is conducted using a Confusion Matrix to measure accuracy levels. The test results show that the model is capable of predicting diabetes diagnosis with an accuracy rate of 76.62%. Based on these results, it can be concluded that the Backpropagation algorithm is effective as an alternative method for early detection of diabetes, although further development is needed to improve the model's sensitivity to positive cases.  

Accreditation is the recognition of the quality of hospital services after an assessment has been conducted to determine whether the hospital has met accreditation standards approved by the government. Every note in the medical record must clearly identify the professional care provider (PPA), including the full name and signature, as well as the date and time of writing. The purpose of this study was to determine how the PPA's identity is filled in in medical records based on accreditation standards at Haji General Hospital, Medan. The research method used was qualitative research, with data collection techniques using in-depth interviews and observation. Six informants participated, including doctors, nurses, and medical records officers. The results showed that despite the existence of Standard Operating Procedures (SOPs) for filling in the PPA's identity, incomplete medical records were still found, such as only including a signature without a clear name and an omitted date and time. Incomplete files were returned to the relevant unit for correction. The main obstacle faced was the PPA's limited working time to complete the medical record files. In conclusion, the PPA's identity is not fully compliant with existing SOPs. Therefore, regular monitoring and evaluation, along with training for all PPAs, are needed to ensure optimal completeness of medical record documentation.

The Hospital Management Information Sistem (SIMRS) is a key component in the digital transformation of healthcare services, aiming to enhance efficiency and service quality. This study evaluates the implementation of SIMRS at Mutiara Bunda Mother and Child Hospital and explores the challenges and opportunities for improvement. A qualitative case study approach was employed, with data collected through in-depth interviews, observations, and document reviews involving five key informants, including the medical records head, medical service manager, registration officers, and IT staff. The results show that the SIMRS covers registration, procedure input, laboratory, and pharmacy functions. However, issues such as delayed data entry by medical staff, limited equipment, lack of integration across service units, and absence of written user guidelines and regular training persist. The study concludes that although the SIMRS is in use at RSIA Mutiara Bunda, sistem optimization, staff capacity building, and stronger managerial support are crucial to fully realize its potential in improving service quality.

This study aims to examine in depth the level of effectiveness and obstacles faced in the use of RME. This study uses a qualitative descriptive approach that aims to describe in depth the effectiveness and obstacles in the use of RME at the Baleendah Health Center. Data collection techniques were carried out through triangulation, namely, observation, interviews, and documentation. The informants in this study consisted of three people, namely the Head of the Puskesmas, medical records officer, and a doctor. Overall, the results showed that the implementation of RME at the Puskesmas received full support from the management, including aspects of funding, training, technology, and regular evaluation of the problems faced. RME has become the main focus because it is considered more effective and efficient than manual systems, especially in accelerating and improving the accuracy of services. However, the implementation still encountered a number of obstacles, such as internet network disruptions in the early stages, which have now been resolved by adding devices at certain points. The limited number of IT experts is also an obstacle because it slows down the handling of technical problems. In addition, server disruptions still occur because data storage is centralized at Diskominfo along with 62 other Puskesmas in Bandung Regency, which causes delays in data access.

This study aims to evaluate and identify the obstacles faced and provide recommendations for improvements to the satisfaction of Electronic Medical Records (EMR) users at Duta Indah Hospital using the End User Computing Satisfaction (EUCS) method. At Duta Indah Hospital the EMR system used is Medinfras. EUCS is used to measure user satisfaction with the application system by comparing user expectations with the reality experienced. This evaluation examines seven variables: content, display (format), accuracy, ease of use, timeliness, speed, and flexibility. This research method uses descriptive quantitative with 63 respondents selected as samples. Data were collected through an online questionnaire, processed using Microsoft Excel 2016 software and analyzed using SPSS Version 25 software with a Likert scale to measure the level of satisfaction. The results showed that the majority of users felt "quite satisfied" with all variables, namely: content (57%), display (57%), timeliness (59%), speed (58%), flexibility (56%), accuracy (54%) and ease of use (54%). In conclusion, the RME system is considered quite adequate in supporting user performance, with accurate information, easy-to-understand displays, and efficiency in time and flexibility. The suggestion for the hospital is to conduct an evaluation, improve the appearance of the system menu so that users can access the system more easily and improve regular system maintenance.

A 60-year-old male patient presented with the chief complaint of numbness in both legs, which had been experienced for the past two years and had worsened over the last three months. This complaint was accompanied by persistent fatigue, even without engaging in strenuous physical activity. In addition, the patient reported frequent urination, especially at night (nocturia), and excessive thirst that had occurred for the past five years. The patient denied symptoms such as fever or disturbances in bowel movements. Regarding his medical history, the patient regularly consumed Glimepiride as part of his treatment for diabetes mellitus. Primary data were obtained through auto-anamnesis and physical examination during a home visit. During the visit, the family physician also completed the family folder and patient records to comprehensively document the patient’s health condition. Case assessment was carried out based on an initial holistic diagnosis, followed by continuous monitoring and final evaluation using both quantitative and qualitative approaches. The interventions provided included health education for the patient and his family regarding the causes and pathophysiology of diabetes mellitus. The physician also emphasized lifestyle modifications, such as adopting a balanced diet, engaging in light but regular physical activity, and maintaining adherence to prescribed medication. Furthermore, the patient was educated on the long-term management of diabetes mellitus and the importance of regular medical check-ups. The family physician also explained the potential complications that could arise, such as neuropathy, nephropathy, and retinopathy, so that the patient would be more compliant with treatment and preventive efforts. This comprehensive approach was expected to improve the patient’s quality of life while preventing further disease progression.

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.

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.

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.

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

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 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.

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.