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The implementation of Electronic Medical Records (EMR) has become an essential part of digital transformation in the healthcare sector, aiming to improve the quality, effectiveness, efficiency, and continuity of healthcare services. In Indonesia, the implementation of EMR is supported by the Regulation of the Minister of Health Number 24 of 2022, which mandates healthcare facilities to adopt electronic medical records. However, the implementation process is often challenged by various technical and non-technical factors that may affect its success. This study aims to analyze the success factors and barriers to EMR implementation in hospitals through a literature review approach. The research method used was a literature review by examining and analyzing 11 scientific articles obtained from Google Scholar and other relevant scientific sources. The findings indicate that the success of EMR implementation is influenced by three main aspects, namely human, organizational, and technological factors. Supporting factors include management commitment, user readiness, continuous training, availability of information technology infrastructure, system quality, and organizational support. Meanwhile, common barriers include limited digital literacy among healthcare workers, insufficient information technology personnel, unstable internet connectivity, system errors, inadequate facilities and infrastructure, budget limitations, and the absence of specific standard operating procedures. Furthermore, EMR implementation provides significant benefits, such as improving service efficiency, facilitating access to patient information, enhancing documentation quality, supporting communication among healthcare professionals, and increasing patient safety. Therefore, successful EMR implementation requires synergy between human resources, organizational readiness, and technological infrastructure to achieve optimal healthcare service delivery.

Background: Cesarean section (CS) is a mode of delivery frequently used in women with high-risk pregnancies. Over the past two decades, the rate of CS has increased significantly worldwide. Although CS can be a life-saving intervention when performed based on appropriate medical indications, it may also result in adverse outcomes for both mothers and infants and increase the clinical and economic burden on healthcare systems. Limiting CS rates can be achieved through the control of modifiable risk factors. Purpose: This study aimed to describe the factors contributing to the occurrence of cesarean section. Method: This study employed a descriptive cross-sectional design and was conducted at Singasana Regional General Hospital, Tabanan Regency, from February to May 2025. The study sample consisted of 259 women who underwent cesarean delivery during the period 2020–2024. Data were collected through a review of medical records using a checklist instrument. Univariate analysis was performed to describe maternal characteristics and indications for cesarean section. Result: Most cesarean deliveries occurred in women aged 20–35 years (77.99%) and in multiparous women (48.65%). The most dominant maternal factor was a previous cesarean section (37.6%), while the most common fetal factor was fetal distress (42.7%). Conclusion: Maternal age of 20–35 years, multiparity, a history of previous cesarean section, and fetal distress were the dominant factors associated with cesarean delivery. These findings highlight the importance of early antenatal risk screening and optimal labor management to reduce unnecessary cesarean sections and improve maternal and neonatal safety.

Vomitus is the forceful expulsion of gastric contents through the mouth, commonly occurring in children as a clinical manifestation of gastrointestinal diseases. Based on medical records of RSUD dr. Soeselo, Tegal Regency, vomitus cases increased to 355 cases in 2025. Therefore, comprehensive nursing care is needed to address problems arising from vomiting in children. This study used a descriptive method in the form of a case study through a nursing process approach, aimed at describing nursing care for a pediatric patient with vomitus. Three nursing diagnoses were identified in An. A with vomitus: Nausea related to gastric irritation/stimulation of the vomiting center, Risk of Fluid Imbalance related to repeated vomiting, and Knowledge Deficit related to lack of information exposure. Nursing interventions provided included Vomiting Management, Fluid Management, and Health Education. After three days of nursing implementation, all three nursing diagnoses were resolved, marked by the disappearance of nausea, improved appetite, normal hydration status (moist mucosa, good skin turgor, pulse 88x/minute), and the patient's mother and patient being able to understand and re-explain health education material about vomitus.

In order to raise the standard of healthcare services in the contemporary period, digital transformation in hospital management has become a phenomena. The purpose of this study is to investigate the adoption, advantages, difficulties, and success aspects of digital transformation in healthcare facilities. A literature review employing a narrative review system was the methodology. 14 papers that met the inclusion requirements were found using data sources from Google Scholar, PubMed, and ScienceDirect databases with publication years ranging from 2020 to 2025. To determine the primary study themes, data analysis was carried out utilising a thematic synthesis approach. According to the study's findings, digital transformation can enhance operational effectiveness, service quality, and patient safety by using technology including electronic health records (EHR), telemedicine, and hospital management information systems. However, there are still a number of obstacles to its adoption, such as inadequate infrastructure, inadequate human resource competency, expensive investment costs, and data security threats. Significant barriers also include a lack of system integration and opposition to change. Government policies and regulatory assistance have an impact on the success of digital transformation in hospital administration.

Background: Lymphadenopathy is an enlargement of the lymph nodes commonly caused by infection or inflammatory processes, which may lead to pain and risk of postoperative complications. This study aims to provide a comprehensive description of nursing care for a patient following left-sided lymphadenopathy surgery. Method: This case study used a nursing process approach, encompassing data collection through interviews, observation, physical examination, and documentation review of medical records conducted in Mawar 2 Ward at RSUD dr. Soeselo, Tegal Regency. Results: Based on assessment, three primary nursing diagnoses were identified: acute pain, knowledge deficit, and risk of infection. Following standard nursing interventions, pain was reduced, patient knowledge improved, and the wound was maintained without signs of infection. Conclusion: The systematic application of nursing care can help reduce patient complaints and prevent postoperative complications of lymphadenopathy.

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.

Preeclampsia is one of the leading causes of maternal mortality and may result in various complications during pregnancy and childbirth. In Tegal Regency, preeclampsia contributed to 27% of maternal deaths in 2024; therefore, studies on childbirth characteristics among mothers with this condition are needed. This study aimed to identify the characteristics of childbirth events in mothers with preeclampsia at Dr. Soeselo Slawi Regional Hospital, Tegal Regency. A descriptive design with a retrospective approach was used by reviewing the medical records of 202 mothers who delivered with preeclampsia during 2025. Data were analyzed univariately and presented as frequency distributions and percentages. The results showed that most mothers underwent operative delivery (62.38%), while spontaneous and induced labor accounted for 37.13% and 0.50%, respectively. Most deliveries occurred at preterm gestational age (62.38%), followed by term (36.14%) and postterm (1.49%) deliveries. Maternal and obstetric complications included bleeding (6.93%), fetal distress (4.95%), eclampsia (1.49%), and HELLP syndrome (0.99%). Most neonates had normal birth weight (82.18%) and did not require NICU care (95.05%), although low birth weight (17.82%) and NICU admission (4.95%) were still identified. The maternal clinical condition was dominated by blood pressure of 140–159/90–109 mmHg (75.74%). Proteinuria was found in 46.53% of respondents, with moderate proteinuria (+2) as the predominant category (38.30%). In conclusion, childbirth among mothers with preeclampsia was dominated by operative and preterm deliveries. These findings emphasize the importance of early detection and optimal management of preeclampsia to reduce maternal and neonatal complications and improve the quality of maternal-infant health services overall.

Background: Adenoid hypertrophy is a condition characterized by enlargement of the adenoid tissue which can cause nasopharyngeal obstruction and potentially affect the function of the Eustachian tube. Dysfunction of the Eustachian tube may disrupt middle ear ventilation and increase the risk of otitis media. The degree of adenoid hypertrophy can be objectively assessed using a lateral nasopharyngeal radiograph by calculating the adenoid–nasopharyngeal ratio (A/N ratio). Objective: This study aimed to determine the relationship between adenoid hypertrophy based on the adenoid–nasopharyngeal ratio and the incidence of otitis media. Methods: This study was a quantitative research with an analytic observational design using a cross-sectional approach. Data were obtained from the medical records of patients with adenoid hypertrophy who underwent lateral nasopharyngeal radiographic examination at RSI Purwokerto from 2022 to 2025. The sample consisted of 31 patients who met the inclusion and exclusion criteria. Data analysis was performed using the Spearman correlation test because the data were not normally distributed based on the Shapiro–Wilk test. Results: The results showed that most of the subjects were male (17 subjects, 54.8%) and female (14 subjects, 45.2%). The median age of the subjects was 7 years with an age range of 4–9 years. The median adenoid–nasopharyngeal ratio was 0.90 with a range of 0.68–0.99. Otitis media was found in 11 subjects (35,5%), while 20 subjects (64,5%) did not experience otitis media. The Spearman correlation test showed a correlation coefficient of r = 0.015 with a p-value of 0.936 (p > 0.05), indicating that there was no significant relationship between the adenoid–nasopharyngeal ratio and the incidence of otitis media. Conclusion: There was no statistically significant relationship between adenoid hypertrophy based on the adenoid–nasopharyngeal ratio and the incidence of otitis media.

Chronic rhinosinusitis (CRS) is a long-term inflammatory condition affecting the nasal mucosa and paranasal sinuses, which significantly impacts patients’ quality of life due to persistent and recurrent symptoms. Limited epidemiological data regarding CRS are available in Central Kalimantan, particularly at RSUD dr. Doris Sylvanus in Palangka Raya, prompting this study to determine its prevalence and patient distribution characteristics. This research employed a quantitative descriptive design with a cross-sectional approach. Data were collected from medical records of patients diagnosed with CRS in 2023 and 2024. Univariate analysis was conducted, and results were presented in tables and diagrams illustrating frequency distributions by year, gender, age, and main complaints. The findings showed a total of 118 CRS patients, with 53 cases in 2023 and 65 cases in 2024. The prevalence of CRS increased from 4.91% in 2023 to 10.83% in 2024. Based on gender, males accounted for 50.8% (60 patients), while females represented 49.2% (58 patients). The age group most affected was 46–55 years (31%), indicating a predominance among individuals of productive age. Nasal congestion was the most frequent primary complaint, reported by 35% of patients. The study concludes that the prevalence of CRS at RSUD dr. Doris Sylvanus increased notably from 2023 to 2024, with a slightly higher incidence among males in the productive age group. These findings highlight the need for enhanced preventive measures and early diagnosis to manage CRS more effectively in the local population.

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.

Breast cancer has a high global incidence and is the most prevalent cancer among women. Chemotherapy is a primary treatment option, but it may cause various physical and psychological side effects that can reduce patients’ quality of life. This study aimed to describe the characteristics of breast cancer patients undergoing chemotherapy and examine the relationship between chemotherapy side effects and quality of life at the outpatient unit of Ciremai Hospital. A cross-sectional analytical observational design was applied, with 30 patients receiving chemotherapy between May and July as the sample. Data were collected from medical records and the Indonesian version of the WHOQOL-BREF questionnaire, then analyzed using Spearman rank correlation. Most patients were aged 40–60 years, had a senior high school education, were housewives, and were in the 2nd or 5th chemotherapy cycle. Frequently reported side effects included nausea, vomiting, decreased appetite, early satiety, dizziness, sleep disturbances, body pain, and alopecia, mostly categorized as moderate. Most patients had a relatively poor quality of life. The analysis indicated a strong positive correlation between chemotherapy side effects and patients’ quality of life, with a Spearman correlation coefficient of 0.604 (p = 0.000 < 0.05), demonstrating a significant and strong relationship.

Breast cancer has a high global incidence and is the most prevalent cancer among women. Chemotherapy is a primary treatment option, but it may cause various physical and psychological side effects that can reduce patients’ quality of life. This study aimed to describe the characteristics of breast cancer patients undergoing chemotherapy and examine the relationship between chemotherapy side effects and quality of life at the outpatient unit of Ciremai Hospital. A cross-sectional analytical observational design was applied, with 30 patients receiving chemotherapy between May and July as the sample. Data were collected from medical records and the Indonesian version of the WHOQOL-BREF questionnaire, then analyzed using Spearman rank correlation. Most patients were aged 40–60 years, had a senior high school education, were housewives, and were in the 2nd or 5th chemotherapy cycle. Frequently reported side effects included nausea, vomiting, decreased appetite, early satiety, dizziness, sleep disturbances, body pain, and alopecia, mostly categorized as moderate. Most patients had a relatively poor quality of life. The analysis indicated a strong positive correlation between chemotherapy side effects and patients’ quality of life, with a Spearman correlation coefficient of 0.604 (p = 0.000 < 0.05), demonstrating a significant and strong relationship.

Data security in Electronic Medical Records (EMR) is a crucial issue in health information governance in Indonesia. This study evaluates the compliance of health facility information security systems with Ministry of Health Regulation (PERMENKES) No. 24 of 2022 and Personal Data Protection Law (UU PDP) No. 27 of 2022, and analyzes the impact of non-compliance on service quality and patient trust. The method employed is a systematic narrative literature review on the Google Scholar database (2023–2026) using the keywords "data security and privacy," "electronic medical records," and "CIA Triad," focusing on the implementation of Confidentiality, Integrity, and Availability. The four healthcare facilities examined have implemented controls such as role-based access control, Electronic Signatures (TTE), Virtual Private Networks (VPN), data encryption, and SSL/TLS protocols in accordance with PERMENKES provisions and Article 35 of the UU PDP. However, the effectiveness of implementation is hindered by weak authentication due to the use of simple passwords and excessively long auto-logout durations, the absence of comprehensive written standard operating procedures (SOPs), low staff compliance with security protocols, and minimal patient awareness regarding personal data protection rights. These weaknesses heighten the risk of patient data breaches as well as potential administrative sanctions and fines, and carry negative implications for service quality and public trust. Recommendations include strengthening internal security policies, developing written SOPs, providing continuous training for healthcare workers, implementing stronger authentication mechanisms (e.g., multi-factor authentication/MFA), and conducting patient awareness programs to ensure regulatory compliance and maintain public confidence.

The implementation of Electronic Medical Records (EMR) is a key component of healthcare digital transformation, as mandated by the Minister of Health Regulation Number 24 of 2022. EMR is expected to enhance efficiency, accuracy, and the quality of nursing services. However, its implementation at M Hospital continues to face challenges, particularly in terms of infrastructure readiness and the digital literacy of nursing staff. This study aims to analyze the effects of infrastructure readiness and digital literacy on the implementation of nursing EMR, with perceived usefulness as an intervening variable. A quantitative cross-sectional design was employed, involving all nurses at M Hospital, with a total sample of 100 respondents using total sampling. Data were collected through structured questionnaires and analyzed using SEM-PLS. The results indicate that infrastructure readiness and digital literacy have both direct and indirect effects on EMR implementation through perceived usefulness (p < 0.05). Among the independent variables, infrastructure readiness demonstrates the strongest influence. These findings support existing theories and prior research. From a managerial perspective, the results highlight the importance of improving infrastructure to optimize EMR implementation. In conclusion, infrastructure readiness and digital literacy significantly influence the successful implementation of nursing EMR, with perceived usefulness acting as a key mediating factor.

Background: Acute respiratory infection (ARI) remains a major public health concern, particularly in primary care settings. Lifestyle factors such as dietary patterns and physical activity are increasingly recognized as potential contributors to respiratory health. Objective: This study aimed to examine the association between dietary patterns, physical activity, and ARI among primary care patients in East Halmahera, Indonesia. Methods: A cross-sectional study was conducted at a primary health care facility in East Halmahera, Indonesia, from January to February 2026, involving 106 respondents selected using a total sampling technique. Data were collected using structured questionnaires and medical records. Variables included sociodemographic characteristics, dietary patterns, physical activity, and ARI status. Data were analyzed using descriptive statistics and Chi-square tests with a significance level of p < 0.05. Results: The prevalence of ARI among respondents was 77.4%. Bivariate analysis showed that dietary patterns (p = 0.006) and physical activity (p = 0.015) were significantly associated with ARI. In contrast, age, gender, marital status, education level, employment status, smoking, and alcohol consumption were not significantly associated with ARI (p > 0.05). Conclusion: Dietary patterns and physical activity were significantly associated with ARI among primary care patients in East Halmahera. These findings highlight the importance of lifestyle-related factors in addressing respiratory infections at the primary care level.  

Dengue Hemorrhagic Fever (DHF) remains a major public health problem in Indonesia, particularly in densely populated areas. Control efforts require accurate data and spatial analysis to understand disease distribution patterns. Geographic Information System (GIS) is an effective tool for visualizing case distribution and supporting surveillance and planning of control programs at the primary healthcare level. This study aims to describe the spatial distribution of Dengue cases based on medical record data and produce a geographic distribution map to support Dengue control efforts at the Puskesmas level. This study used a quantitative descriptive design with secondary data from medical records at Karangsari Health Center. The sample consisted of 255 DHF patients in 2025, selected using a total sampling technique. Data were processed through editing, geocoding patient addresses, and spatial analysis using QGIS software.The results showed 255 Dengue  cases in 2025 with fluctuating monthly trends, peaking in April and lowest in December. Case distribution was uneven and tended to cluster. High-risk areas accounted for 15.7%–21.2%, moderate-risk areas 9.8%–15.7%, and low-risk areas 7.1%–9.8%. Megu Cilik Village had the highest proportion of cases, while other villages were categorized as moderate and low risk. This pattern indicates that Dengue incidence is influenced by environmental conditions, vector density, host factors, rainfall, and Aedes aegypti presence. GIS provides clearer spatial visualization, helping identify high-risk areas and supporting targeted public health interventions.

The right to privacy and the right to health are fundamental human rights that are closely interconnected. The protection of privacy for patients with Human Immunodeficiency Virus (HIV) constitutes a critical issue, given that HIV status is classified as highly sensitive health data and is particularly vulnerable to stigma and discrimination. In Indonesia, the legal framework governing the protection of HIV patients’ health data has been normatively strengthened through the Personal Data Protection Law and the Health Law; however, its implementation continues to face various challenges. This article aims to analyze the right to privacy of HIV patients and the obligations of the state in protecting sensitive health data, as well as to examine the limitations and exceptions to the disclosure of HIV-related data within the framework of law and human rights. This study employs a normative legal research method using statutory, conceptual, and human rights-based approaches. Legal materials are analyzed qualitatively through juridical interpretation and prescriptive analysis. The findings indicate that HIV status is legally categorized as sensitive personal data that is entitled to a high level of legal protection. The state bears tripartite obligations to respect, protect, and fulfill the privacy rights of HIV patients. Nevertheless, a gap persists between legal norms and their implementation, particularly in the management of electronic medical records. The protection of HIV patients’ privacy rights requires strengthened legal implementation, regulatory harmonization, and the adoption of a human rights-based approach to ensure that data protection does not conflict with public health interests.

This regulation, which requires all healthcare facilities to implement EMR by December 31, 2023, stemmed from the emergence of Health Ministerial Regulation No. 24 of 2022. Santosa Hospital, Bandung Kopo, has implemented EMR, but no research has been conducted on it. This study aimed to determine the effect of EMR implementation on service quality in the emergency unit at Santosa Hospital, Bandung Kopo. The research methods used were descriptive verification analysis and multiple linear regression analysis. Data collection used a questionnaire distributed to all emergency unit staff. The results of the descriptive analysis were generally considered very good. The results of the verification analysis, both partially, showed a negative and insignificant effect on system quality and service quality, while information quality and use statistics showed a positive and significant effect. Simultaneously, these positive and significant effects were proven, and the researchers recommend maintaining and further improving them.

This reflective autoethnographic study explores the lived experience of being an only child caring for an elderly mother with Parkinson's disease while working as a full-time lecturer. The research aims to understand how this dual role affects the caregiver's mental health, work productivity, and relationship with the mother. Using a reflective autoethnographic approach based on Ellis, data were collected through three techniques: autobiographical narratives and memos, analysis of personal artifacts (work schedules, medical records, photographs), and an integrated self-interview. Thematic-reflective analysis revealed three main themes. First, structural loneliness describes the profound isolation resulting from having no sibling to share physical, emotional, and decisional responsibilities, which informal support cannot easily remedy. Second, stealth strategies at work refer to hidden tactics such as leaving early without disclosure, using breaks to check on the mother, and concealing caregiving struggles to avoid being perceived as less committed or losing professional opportunities. Third, fought for bonds shows that despite exhaustion and initial frustration, the caregiver’s relationship with her mother deepened through daily effort, patience, and reframing caregiving as meaningful devotion, a process aligned with filial maturity. The findings highlight the unique pressures faced by only-child working caregivers, including invisible productivity loss and the inadequacy of general social support. Practical implications for employers, social workers, and policymakers are discussed. This study contributes a rich first-person account to the underexplored area of only-child caregiving and offers recommendations for workplace cultural change, targeted support groups, and subsidized respite services.