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The implementation of the Hospital Information Management System (SIMRS) plays a crucial role in enhancing the quality of public healthcare services in Indonesia. With the country's vast geographical landscape and significant disparities in healthcare access between urban and rural areas, SIMRS offers an integrated digital solution to streamline hospital operations and improve service delivery. This study explores the impact of SIMRS on the efficiency of hospital management, particularly in administrative processes such as patient registration, medical records, and resource allocation. Additionally, SIMRS contributes to improving healthcare accessibility by enabling seamless data exchange between healthcare facilities, ensuring that patients in remote areas can access timely and appropriate care. Despite its benefits, the implementation of SIMRS faces challenges, such as limited infrastructure, high implementation costs, and a lack of trained personnel. To overcome these obstacles, it is essential for the government, healthcare institutions, and other stakeholders to collaborate in providing adequate training, improving infrastructure, and ensuring sustainable implementation of SIMRS. This study concludes that SIMRS has the potential to significantly improve healthcare services in Indonesia, provided that the challenges are addressed and adequate support is given for its expansion across the country.

Knowledge about mental illness for Bhnike Karya Karanganyar Vocational School students is still limited. Knowledge about waste disposal management is important to provide as an effort to equip oneself to maintain personal health (Radiani, 2019).   If mental disorders are not treated properly, they will get worse and can ultimately burden families, society and the government. The method used in this paper is exploratory descriptive analysis, through literature reviews and secondary data studies. The research results show that a study of the 2018 Riskesdas data shows that the prevalence of serious mental disorders in the Indonesian population is 7% (per mile of population) and is mostly found in Bali, Yogyakarta, NTB and Aceh.  It is hoped that similar activities can have an impact on increasing awareness of the Indonesian people, especially students and female students as the younger generation, to actively participate in maintaining mental health. On this occasion, the Community Service Implementer of the D3 Medical Records and Health Information Study Program, Faculty of Health Sciences, Duta Bangsa University, Surakarta will carry out P2M activities for Bhina ​​Karya Karanganyar Vocational School students regarding mental illness. On this occasion, the Community Service implementer expressed his thanks to the Head of the School and the Head of Public Relations at Bhina ​​Karya Karanganyar Vocational School for providing permission for a place to carry out Community Service activities. Hopefully this activity will be useful for increasing the knowledge of Bhina ​​Karya Karanganyar Vocational School students regarding mental illness in the hope that their knowledge will be aware of maintaining mental conditions for the sake of mental health itself.

The implementation of electronic medical records at Hidayah Boyolali Hospital from January 2023 until now is not free from risks. The risks that generally occur are incomplete filling out of electronic medical records due to doctors' indiscipline in filling out patient treatment histories, inappropriate access to medical record information due to errors in patient identification, and errors in coding patient diagnoses which cause difficulties in claims and inappropriate service financing. The aim of PkM is to increase the knowledge and skills of medical record officers regarding hybrid medical record risk management. The PkM stages are: (1) preparation and licensing, (2) presentation of material and case studies, and (3) evaluation. The results of PkM are increased knowledge and ability to identify risks, assess risks, and treat risks in hybrid medical records. Implementation of risk management is carried out in the patient registration unit, patient data processing unit, patient data storage unit, and medical information release unit.

Background: According to the Regulation of the Minister of Health of the Republic of Indonesia Number 24 of 2022 concerning Medical Records, they are documents that contain patient identity data, examinations, treatment, procedures and other services that have been provided to patients. Minimum Hospital Service Standards Completeness of filling in medical records 24 hours after completion must reach 100%. Objective: To determine the completeness factor in writing the patient's name in the patient's medical record at the hospital. Method: This research uses a literature review method. Results: The highest percentage of completeness in writing patient names was in research journals with a percentage of 98%, while the lowest percentage was 56%. Conclusion: From the results of a review of the completeness of writing patient names in hospital medical records, it was found that the completeness results were not 100% and not all hospitals had SOPs regarding procedures for writing patient names. Suggestion: Create an SPO for procedures for writing patient names that comply with standards so that officers can carry out these activities with guidelines. Background: In accordance with Republic of Indonesia Health Minister Regulation Number 24 of 2022, medical records are records that include information about a patient's identity, medical examinations, treatments, procedures, and other services rendered to them. Minimum Requirements for Hospital Services Within 24 hours of finishing, all medical records must be 100% complete. Goal: To ascertain the degree of completeness in entering the patient's name in the hospital's medical file. Method: A literature review approach is used in this study. Findings: Research journals had the highest percentage of complete patient names (98%) and the lowest percentage (56%) of complete patient names. Conclusion: A review of the completeness of writing patient names in hospital medical records revealed that not all hospitals have standard operating procedures (SOPs) pertaining to patient name writing, and the findings were not 100% complete. Recommendation: Establish a standard operating procedure (SPO) for writing patient names that adhere to standards so that officers can perform these tasks in accordance with protocols.

Dengue fever (DHF) is an infectious disease caused by the dengue virus and transmitted through the bite of the Aedes aegypti mosquito. This disease is a major health problem in many tropical countries, including Indonesia. Identification and classification of DHF patients is very important to prevent further spread and to provide appropriate medical treatment. In this study, the classification of DHF disease is carried out using the K-Means algorithm, which is one of the methods in machine learning used to classify data based on similarity of features. This study aims to apply the K-Means algorithm in classifying DHF cases based on data on symptoms that appear in patients, such as high fever, joint pain, skin rashes, and others. The data used includes patient medical records that record various clinical and demographic parameters. The K-Means algorithm is used to group the data into clusters that describe the severity category or potential risk of dengue disease. The results showed that the K-Means algorithm can be used to cluster DHF patients well, with the division of groups that can describe the severity of the disease. Evaluation was conducted using metrics such as silhouette and cluster validity to assess the effectiveness of the algorithm in performing classification. This model is expected to help medical personnel in decision-making, provide early warning, and improve rapid response to dengue cases.

This Electronic Medical Record is a digital version of a medical record, the same as a paper-based manual medical record, this electronic medical record also contains information regarding health history, diagnoses, laboratory results, examination notes, medications given, medical procedures, and other data. relevant to the patient's health condition. It is hoped that the implementation of Electronic Medical Records can increase the efficiency of BPJS claims and improve the quality of service. Therefore, this study aims to analyze the use of RME using the Delone and Mclean method. The Delone and Mclean method is an information system quality evaluation framework that includes six dimensions, namely information system quality, information quality, service quality, use quality, user satisfaction, and user impact. In this study, we apply this method to analyze the quality of RME management. This research uses a quantitative approach by collecting data through questionnaires distributed to RME users in hospitals. The questionnaire measures user perceptions of information system quality, information quality, service quality, use quality, user satisfaction, and impact of using RME. The results of this research are expected to provide better insight into the use of RME in the context of work efficiency. The findings of this research will provide input for RME developers to improve the quality of information systems, the quality of information, and the quality of services provided to users. Apart from that, this research also contributes to theory and research in the field of information systems by applying the Delone and Mclean method in the context of RME management.

Hypertension in pregnancy is hypertension that occurs when blood pressure is first detected in a mother who is known to have normal blood pressure but after 20 weeks of gestation who does not have significant urine protein and other characteristics of preecamsia. Then, data was obtained from the Health Profile of North Sumatra Province. The aim of this research was to analyze the factors that influence the occurrence of hypertension in pregnant women at the Peureulak Community Health Center. This research was quantitative with a case control research design. The population for conducting this research was all pregnant women registered in the register book at the Peureulak Community Health Center in 2023 In this study, a total sampling technique was used, namely all pregnant women recorded in the Peureulak Health Center's medical records in 2023. Population. This analysis requires several stages, namely: analysis of proportions or percentages, analysis of statistical test results and analysis of the close relationship between two variables. Bivariate analysis was carried out on two variables that were thought to be related or correlated. The conclusion from the results obtained was 0.000, where the results showed <0.05 that there was a significant relationship between parity and the incidence of hypertension.    

Security of electronic medical records (EMR) data is very important in maintaining the confidentiality, integrity, and availability of sensitive patient information. This study aims to conduct a security analysis of the EMR application used at UPTD RSD Besemah Pagar Alam City using the Penetration Testing method. This method is carried out to identify, exploit, and provide solutions to potential vulnerabilities in the EMR application system. Penetration Testing is carried out through several stages, namely information collection, scanning, exploitation, and post-exploitation, using tools such as Nmap, and OWASP ZAP. The results of the study showed several vulnerabilities in the application, including SQL Injection, Cross-Site Scripting (XSS), and weaknesses in authentication management that could allow unauthorized access to patient data. In addition, exposure to sensitive data that was not properly protected was also found. Based on the results of this test, several recommendations were made to improve system security, such as updating security patches, implementing encryption on all sensitive data. By implementing the recommended mitigation steps, the security of the EMR system at UPTD RSD Besemah is expected to be significantly improved, so that the risk of data leakage can be minimized. This research provides a real contribution in strengthening the security of electronic medical record applications. and is expected to be a reference in improving security systems in other health care institutions.    

Background: The process of managing medical records at Dharma Yadnya General Hospital is not in accordance with the work procedures and organization of health service facilities. This can be seen from incomplete medical records, doctor writing is not specific in diagnosis and human error which results in errors in taking medical records. Purpose: This study aim to evaluate the process of managing patient medical records at Dharma Yadnya General Hospital. Method: This research is descriptive qualitative using in-depth interviews. The sampling technique used purposive sampling method with a sample of 6 people. Results: Based on the analysis results, 5 themes were discussed, namely assembling, filling, coding, indexing, filling and retention activities. Overall, the management of patient medical records at Dharma Yadnya Hospital has not been able to run optimally, namely the filling of incomplete medical record documents, namely patient identity, diagnosis, medical resume, signature of the doctor in charge of the service and there are still errors in placing medical records (missfiles) so that the management of medical records takes a long time so that the assembling, coding, indexing, filling and retention processes are hampered. Conclusion: The management system of patient medical records at RSU Dharma Yadnya starting from assembling, coding, indexing, filling and retention have not been run optimally.

Maternal health remains a major global challenge, particularly in developing countries where mothers are still highly vulnerable during childbirth. Postpartum hemorrhage is one of the leading causes of maternal mortality, accounting for approximately 25% of maternal deaths worldwide, and commonly occurs within the first 24 hours after delivery. This study aims to identify factors associated with postpartum hemorrhage at Bakti Timah Pangkalpinang Hospital during 2022–2023. The research applied a case-control design using secondary data obtained from medical records. The study population consisted of 1,002 mothers who gave birth at the hospital, with a sample of 104 respondents divided into 52 case subjects (mothers who experienced postpartum hemorrhage) and 52 control subjects (mothers who did not experience postpartum hemorrhage). Data were analyzed using the Chi-square test. The results showed significant relationships between maternal age (p=0.002; OR=3.600; 95% CI: 1.548–8.371), parity (p=0.000; OR=0.194; 95% CI: 0.079–0.477), and anemia (OR=5.099; 95% CI: 1.940–13.399) with the incidence of postpartum hemorrhage. The study concludes that mothers aged under 20 years and over 35 years, multiparous mothers, and mothers with anemia have a higher risk of experiencing postpartum hemorrhage.

The maternal mortality rate (MMR) is an indicator of the success of health services in Indonesia. Maternal mortality can indicate that maternal mortality can occur due to anemia. The maternal mortality rate is 60% for anemic mothers and 19.9% ​​for those who are not anemic. The purpose of this study was to determine the risk factors for anemia in pregnant women at PMB T, Rembang  in 2024. The type used was a retrospective cohort study and the statistical test used in this study was the Chi-square test. The population in this study were all pregnant women who were recorded in the Medical Records of PMB T in 2024 as many as 151 people with a total sample of 60 respondents who were taken by random sampling method. The results showed that there was a relationship between mother's education (p.value = 0.002), mother's occupation (p.value = 0.002), age (p.value = 0.003) and nutritional status (p.value = 0.021) with the incidence of anemia in pregnant women in PMB T. The conclusion of this study is that education, occupation, age and nutritional status are related to the incidence of anemia in pregnant women. Suggestions are that it is hoped that health workers can increase knowledge in the community, especially pregnant women by providing counseling or counseling about the problem of anemia.

Colorectal cancer is a malignant epithelial tumor originating from colorectal mucosa. Clinicopathology factors including age, gender, location, histopathological type, differentiation, depth of invasion, lymph node metastasis, and lymphovascular invasion are known affect the prognosis. This study aims to determine the clinicopathological characteristics of colorectal cancer at Anatomical Pathology Laboratory RSUP. Dr. M. Djamil Padang in 2017-2020 This study was descriptive observational with total sampling technique from medical records. Samples included all colorectal cancer patients in 2017-2020 who were fulfilled inclusion criteria, with total 251 samples. The results showed that the most patiens were female (52.2%), the age group were > 50 years (66.1%), mostly located in the rectosigmoid (71.7%). Most of the histopathological types were adenocarcinoma (79.7%), with low grade differentiation (88.8%). More than a half of tumor invasion was at T3 (58.2%). Mainly metastatic status to lymph nodes was Nx (54.2%) and lymphovascular invasion were positive in 60% samples that included the lymphovascular invasion examination. The conclusion of this study is most of colorectal cancer in Anatomical Pathology Laboratory RSUP. Dr. M. Djamil Padang in 2017-2020 are in advanced stage, Early detection needs to be done so that colorectal cancer can be diagnosed at an early stage.

There are eight different uses for medical records: administrative, legal, financial, research, educational, documentation, public health, planning, and marketing. This study aimed to determine the relationship between knowledge about medical records use value and the behavior of filling out medical record documents by nurses in inpatient room at Mitra Medika Hospital Tanjung Mulia Medan in 2023. This is quantitative research with analytic survey design and used cross sectional approach. The statistical test used spearman rank test. The population in this study were all nurses who worked in Inpatient Room of the Hospital with 89 people and all were sampled. The results of Spearman rank test with a confidence level of 95% or alpha (a) = 0.05 obtained a p value = 0.002, it can be concluded that there was a significant relationship (meaningful) between knowledge of the use value of medical records and the behavior of filling out medical record documents. The correlation coefficient obtained through the Spearman rank statistical test or r value was = 0.319. According to cross tabulation, the results of data analysis (statistical test) are p value (significant value) = 0.002 a = 0.05, indicating that there is a meaningful relationship (significant relationship) between knowledge of the value of using medical records and the practice of filling out medical record paperwork. It is suggested that in order to improve the accuracy of filling up medical record documents, respondents broaden their understanding of the importance of medical records and their use by reading books, articles, and other reading materials.

Leprosy is a chronic infectious disease caused by Mycobacterium leprae that attacks several parts of the body, especially the upper respiratory tract, skin, and peripheral nerves. Indonesia is the third country with the most leprosy in the world. This study aims to determine the profile of leprosy patients at the Dermatology and Venereology Polyclinic Dr. M. Djamil Padang Hospital in 2018-2021. This research is descriptive retrospective with total sampling technique using secondary data in the form of medical records. The sample of this study were all leprosy patients in 2018-2021 who were fulfilled inclusion criteria, with a total of 39 patients. The results showed that the most age group was >14 years (100%), the most gender was male (74.36%), the most residence was Padang (33.33%), and almost all leprosy patients (92.31%) had no history of household contact with leprosy patients. Most of the leprosy patients were of the multibacillary type (74.36%) with positive smear results (46.15%), without leprosy reaction (61.54%), and the most disability level that occurred was grade 0 disability (48.72%). The conclusion of this study is that most cases of leprosy at the Dermatology and Venereology Polyclinic RSUP Dr. M. Djamil Padang in 2018-2021 aged >14 years, male, having address in Padang City, had no history household contact, multibacillary type, positive smear result, without reaction, and level 0 disability.

Vaccination actively seeks to create/increase a person's immunity against disease. Vaccination protects children from several immunization-preventable diseases (VPD).  The aim of this study is to determine the relationship between age and parity and the incidence of retained placenta in mothers giving birth at the Sonomartani Labura Health Center in 2023. The population in this study includes all women giving birth with retained placenta and recorded in the medical records in January 2022-December 2022 at the Sonomartani Labura Health Center as many as 16 patients. Data analysis using univariate, bivariate analysis. The results of this study show the relationship between age and parity and the incidence of retained placenta in mothers giving birth at the Sonomartani Labura Community Health Center in 2023.

Background: Radiology plays a vital role in modern healthcare, offering diagnostic and therapeutic services. RSU Bunda Thamrin Medan provides comprehensive radiology services, ranging from X-ray to CT scan, MRI, and ultrasound. Objective: This study aims to analyze the characteristics of radiology examinations performed at RSU Bunda Thamrin Medan from January to July 2024. Methods: A retrospective, descriptive observational study was conducted. Data from 18,986 patients were collected from medical records, including age, gender, and type of examination. Results: X-ray was the most frequent examination (70.2%), followed by ultrasound (16.6%). Most patients were between 21-50 years of age, with a near-equal distribution between male and female patients. CT scan and MRI were used in more specific cases. Conclusion: X-ray and ultrasound dominate radiological examinations, reflecting their broad utility in diagnosis. CT and MRI, though less frequent, are crucial for complex cases. Continuous equipment maintenance and staff training are needed to support the increasing demand for radiology services.

One measure of neonatal health is birth weight. Both the mother's weight increase and her overall health during the pregnancy have an impact on the baby's birth weight. This study sought to ascertain how pregnant women's weight gain related to the interpretation of fetal weight prior to delivery at Telogorejo Semarang Hospital. Research Design: Correlation design using quantitative research methodology. All of the pregnant patients that underwent ANC at Telogorejo Hospital in April 2024 made up the study's population. Purposive sampling was the method employed in the sampling process. acquired a 52-person sample. instruments for gathering data from medical records. Chi square testing is the method employed. Findings: Pregnant women's weight gain and fetal weight gain prior to birth have a substantial correlation (p = 0.000). As many as 24 respondents (46.2%) reported a normal weight gain of 9–12 kg, and as many as 22 respondents (42.3%) reported a fetal weight of more than 2.9 kg. Conclusion: At SMC Telogorejo Hospital, there is a noteworthy correlation between pregnant women's weight rise and the weight gain of the fetus prior to birth. Recommendation: The hospital should prepare a strategy for early identification of changes in weight gain during pregnancy that could affect the developing fetus and for counseling.

The social assurance program in Indonesia is formed by legal organization called Badan Penyelenggara Jaminan Sosial (BPJS) which is expected to provide appropriate health facilities for the middle low community. One of the diagnoses and surgery claimed by BPJS Kesehatan is sectio caesar where the caesar section has been increased significantly year by year, but there so many factors that effect the claim process before submitted to the BPJS. The purpose of this research is to find out what the factors that related to the submitting medical record for BPJS claims and how many files are returned from the casemix section to the BPJS claim process for sectio caesar patients at Pakuhaji Public Hospital. The sample of this study is 97 medical records of sectio Caesar patient that will be proceed for the BPJS claim. This study used a quantitative cross-sectional approach. This study found that incomplete medical record doucment and incorrect codes. And the result of this study is the completeness of the file and the accuracy of the code had a significant relation with the claim process, meanwhile the file collection at Pakuhaji Public Hospital hasn’t relation with the claim process because the results were constant. From the result, will be better if Pakuhaji Public Hospital provides the socialization, training for medical records officer and cross-checking medical records file completeness and code accuracy before being submitted to casemix so that in the future it will facilitate the claim process.

The emergence of telemedicine as a digital transformation in the healthcare industry is a remarkable innovation that merges cutting-edge technology with community involvement. The progress has been found to enhance the quality of healthcare services but also poses challenges to ethical values in medicine that must be upheld to safeguard human dignity. Consequently, there is a pressing need to reform laws that can safeguard both healthcare providers and patients. Suggested legal reforms include modifying medical practice regulations to ensure equitable legal protection for doctors and patients during telemedicine consultations and bolstering the use of medical records as evidence in conflict resolution. These measures are aimed at ensuring that technological advancements in healthcare align with the values of Pancasila, which prioritize scientific values, fairness, justice, humanity, and balance, as well as the safety and protection of patients.

Clinical Features of End Stage Renal Disease (ESRD) will appear if urea blood levels is more than 200 mg/dl. Uremia can cause malfunctioning of all organ systems, such as; disorder of fluid and electrolyte balance, endocrine- metabolic, neuromuscular, cardiovascular and lung, skin, gastrointestinal, hematology and immunology systems. The objective of this study was to determine the clinical features of patients with ESRD that undergoing hemodialysis at RS Tk.II dr. Soedjono Magelang. This was a descriptive observational method based on secondary data obtained from medical records. Samples included all patients with ESRD underwent hemodialysis at RS Tk.II dr. Soedjono Magelang in 2023 who were fulfilled inclusion criteria, with total 104 samples. Data were analyzed by using univariate analysis. The study showed that patients with ESRD were mostly at ranged 40 to 60 years (62.5%) and predominantly men (59 patients, 56.7%). The most clinical features of the patient were moderate nutritional status (94.2%), with Hb concentration 7-10g/dl (68.3%), conjunctival anemia (62.5%), peripheral edema (53.8%), stage 1 hypertension (32.7%), weakness and tired (30.8%), and nausea (12,7%). The conclusion is the most common clinical features of the patients with ESRD undergoing hemodialysis at RS Tk.II dr. Soedjono Magelang were anemia, with first stage hypertension, moderate nutritional status and peripheral edema.