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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.

Diabetes Mellitus (DM) is a metabolic disease with an increasing prevalence and a risk of causing macrovascular complications such as stroke. This study aimed to describe the characteristics of Diabetes Mellitus patients with stroke complications based on CT-scan results at RSKD Dadi Makassar in 2024–2025. This was a descriptive observational study with a retrospective design using medical record data. Samples were taken using a total sampling technique, comprising 60 patients, and analyzed univariately using the Statistical Product and Service Solutions (SPSS) version 26. The results showed that the majority of respondents were in the late elderly group (>56 years) at 66.7%, female (51.7%), and from the Makassar ethnic group (63.3%). Most respondents experienced hyperglycemia in random blood glucose (66.7%) and had uncontrolled fasting blood glucose (68.3%) and HbA1c (76.7%) levels. CT-scan results were dominated by non-specific cerebral infarction (68.3%), with ischemic stroke as the most common type (93.3%), a length of stay of 5–10 days (53.3%), and right-sided hemiparesis as the most common clinical manifestation (45.0%). It was concluded that DM patients with stroke complications were generally elderly, female, had poor glycemic control, and were dominated by ischemic stroke with non-specific cerebral infarction. Abstrak. Diabetes Melitus (DM) merupakan penyakit metabolik dengan prevalensi yang terus meningkat dan berisiko menimbulkan komplikasi makrovaskular berupa stroke. Penelitian ini bertujuan untuk mengetahui gambaran karakteristik pasien Diabetes Melitus yang mengalami komplikasi stroke berdasarkan hasil CT-scan di RSKD Dadi Makassar tahun 2024–2025. Penelitian ini merupakan penelitian observasional deskriptif dengan desain retrospektif menggunakan data rekam medis. Sampel diambil dengan teknik total sampling sebanyak 60 pasien dan dianalisis secara univariat menggunakan Statistical Product and Service Solutions (SPSS) versi 26. Hasil penelitian menunjukkan mayoritas responden berusia lansia akhir (>56 tahun) sebanyak 66,7%, berjenis kelamin perempuan (51,7%), dan berasal dari Suku Makassar (63,3%). Sebagian besar responden mengalami hiperglikemia pada GDS (66,7%) serta memiliki kadar GDP (68,3%) dan HbA1c (76,7%) yang tidak terkontrol. Hasil CT-scan didominasi oleh infark serebri tidak spesifik (68,3%) dengan jenis stroke terbanyak berupa stroke iskemik (93,3%), lama rawat inap terbanyak 5–10 hari (53,3%), dan manifestasi klinis tersering berupa hemiparese dextra (45,0%). Disimpulkan bahwa pasien DM dengan komplikasi stroke umumnya berusia lanjut, berjenis kelamin perempuan, memiliki kontrol glikemik yang buruk, dan didominasi oleh stroke iskemik dengan gambaran infark serebri tidak spesifik.

Gastroesophageal Reflux Disease (GERD) merupakan gangguan saluran pencernaan di mana isi lambung berulang kali kembali ke kerongkongan, menyebabkan berbagai gejala dan komplikasi. Prevalensi GERD di Indonesia pada tahun 2023 dilaporkan sebesar 42,3% dengan 274.396 kasus. Data rekam medis RSUD Banyumas menunjukkan peningkatan kasus GERD dari 71 kasus (2023) menjadi 118 kasus (2024). Tujuan: Mendeskripsikan penerapan asuhan keperawatan pada pasien Nn. S dengan Gastroesophageal Reflux Disease (GERD) di Ruang Melati RSUD Banyumas. Metode: Studi kasus deskriptif dengan pendekatan proses asuhan keperawatan, dilakukan pada tanggal 27–28 Januari 2026 di Ruang Melati RSUD Banyumas melalui wawancara, observasi, pemeriksaan fisik, studi dokumentasi, dan studi literatur. Hasil: Diagnosis keperawatan yang muncul adalah nyeri akut berhubungan dengan agen pencedera fisiologis (D.0077), nausea berhubungan dengan gangguan pada esofagus (D.0076), dan defisit pengetahuan berhubungan dengan kurang terpapar informasi (D.0111). Intervensi yang dilakukan meliputi manajemen nyeri, manajemen mual, dan edukasi kesehatan. Kesimpulan: Setelah dilakukan implementasi keperawatan selama 2 hari, diagnosis nyeri akut dan nausea teratasi sebagian, sedangkan diagnosis defisit pengetahuan teratasi penuh. Discharge planning dilakukan dengan menganjurkan teknik relaksasi napas dalam, aromaterapi minyak kayu putih, serta modifikasi pola hidup sehat.

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.

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.

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 study aims to develop a web-based Electronic Medical Record (EMR) application to improve the efficiency and accuracy of patient data recording at Elopada Community Health Center. The research adopts a system development approach using the waterfall model, including requirements analysis, system design, implementation, and testing. Data were collected through observation, interviews, and documentation. The developed system was evaluated using Black Box Testing to verify the conformity between input and output without considering internal program structures. The results indicate that the EMR system enhances data processing speed, improves recording accuracy, and facilitates access to patient information. These findings are consistent with prior studies showing that EMR implementation improves the quality and efficiency of clinical documentation . Therefore, the proposed system is considered feasible to support the advancement of digital healthcare services.

The digital transformation of healthcare requires hospitals to optimally implement Electronic Medical Records (EMR) in accordance with the National Hospital Accreditation Standards (SNARS). However, challenges remain related to human resource readiness and the effective use of EMR to support KARS accreditation and service quality improvement. This community service activity aimed to provide assistance in implementing SNARS-based EMR at Mitra Sejati General Hospital, Medan. A descriptive–qualitative approach was applied through education, structured training, focused group discussions, and peer group mentoring involving healthcare professionals and supporting staff. The results demonstrated an improvement in participants’ understanding of SNARS, increased compliance of EMR implementation with KARS standards, and enhanced quality and traceability of medical record documentation. The assistance also improved hospital readiness for accreditation and contributed to quality and patient safety improvement. It can be concluded that SNARS-based EMR implementation assistance is an effective strategy to support KARS accreditation and enhance hospital service quality.

Weight gain can be a concern for some women, with some considering a body conforming to specific beauty standards as an ideal or desired goal. The use of progesterone hormone injections, which affect the appetite control center in the hypothalamus, can increase appetite and potentially lead to weight gain. This research employs a descriptive-analytical method with a quantitative approach conducted at the Independent Midwife Practice in the working area of the Kragilan Serang Community Health Center, Banten, using secondary data from medical records. Data collection involved 96 respondents divided into 48 samples of 1-month injectable contraceptive (KB Suntik) users and 48 samples of 3-month injectable contraceptive users. The total research sample size is 96 respondents, with the majority falling in the 20–40 age group and the remainder aged >40 years. The results indicate that among the 48 respondents using the 1-month injectable contraceptive, the average weight gain is 0. 938 kg, while for the 3-month injectable contraceptive, the average weight gain is 4. 251 kg.

Electronic Medical Records (EMR) are crucial for the quality of healthcare services, but compliance remains a challenge. This study analyzed factors influencing compliance among healthcare workers at a type B private hospital in North Jakarta using a quantitative cross-sectional design with 58 respondents through total sampling. Data were obtained through questionnaires related to individual factors (age, length of service, knowledge), psychological factors (attitude, motivation), and organizational factors (leadership, work design, rewards). The results showed that 72.4% of respondents were compliant. The chi-square test revealed a significant relationship between compliance and age (p=0.042), length of service (p=0.000), knowledge (p=0.001), attitude (p=0.017), motivation (p=0.002), leadership (p=0.046), and rewards (p=0.010), while work design was not significant (p>0.05). Multivariate analysis found age, length of service, knowledge, and leadership as the dominant factors. Healthcare workers with younger age, shorter tenure, good knowledge, positive attitudes, high motivation, good leadership, supportive work designs, and adequate reward systems tend to have higher compliance rates. Improving compliance in completing EMRs depends not only on individual factors but also requires organizational support through effective leadership and management systems. Recommended interventions include improving digital literacy, regular training, strengthening a work culture that emphasizes the importance of medical documentation, and implementing peer learning strategies among healthcare workers to accelerate adaptation and share best practices in completing EMRs.

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.

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.

Patient satisfaction is a feeling that arises from the performance of health services that have been obtained after the patient compares it with what was expected. Rather than the reality that occurs there are still complaints about outpatient registration services based on electronic medical records, Frequent obstacles are if the network is disrupted, then access to the EMR can be hampered or cannot be accessed at all and the limited capacity of the waiting room is also an obstacle, especially with the large number of patients during peak hours so that many patients wait outside the waiting room. This study aims to determine the level of patient satisfaction in outpatient registration based on EMR. This study uses a quantitative method with a population of 13,750 and a sample of 99 outpatients. Based on the results of the study in 2025, it can be concluded that patient satisfaction with RME-based outpatient registration in the aspect of tangibles can be categorized as "Less Satisfied" especially regarding facilities such as AC/Television, from the aspect of reliability it can be categorized as "Satisfied" even though there are a few respondents who answered "Less Satisfied", from the aspect of responsiveness it can be categorized as "Satisfied" even though there are some patients who feel "Less Satisfied", from the aspect of assurance in RME-based outpatient registration it can be categorized as "Satisfied" but there are a small number of patients who answered "Less Satisfied" and from the aspect of empathy it can be categorized as "Satisfied" even though there are some patients who answered "Less Satisfied". So the researcher's suggestion is that the Hospital improves the quality of the waiting room, especially AC, television, increases the number of chairs and provides adequate seating for all patients, so that patients are more comfortable and avoid overcrowding

Infertility in women is a reproductive health issue that requires early intervention to prevent long-term effects. With the advancement of technology, electronic medical records data can be utilized to assist in the diagnosis and classification of infertility risks. This study aims to classify the risk of infertility in female patients using the Naive Bayes algorithm based on medical record data, which includes factors such as age, health history, and medical test results. The data used in this study were obtained from hospitals and health clinics focused on managing infertility patients. The methods applied include data preprocessing, applying the Naive Bayes algorithm for classification, and evaluating the model using accuracy, precision, recall, and F1-score metrics. The results of the study show that the Naive Bayes algorithm provides fairly accurate classification in predicting infertility risks. The analysis-generated graph shows the distribution of infertility risks, with 60% of patients having a positive risk (1) and 40% having a negative risk (0). This study also suggests implementing the classification results in the form of counseling for patients to increase awareness and encourage early preventive actions. Thus, the Naive Bayes algorithm can be an effective tool in assisting healthcare providers in data-driven decision-making to address infertility risks in female patients.

Menulis artikel ilmiah seringkali menjadi tantangan tersendiri bagi mahasiswa. Beberapa kesulitan yang dihadapi mahasiswa dalam menulis diantaranya membuat parafrase kalimat, menyajikan dan menjelaskan data hasil penelitian, terbatasnya referensi, hingga rendahnya motivasi dalam menulis. Oleh karena itu, diperlukan kegiatan pelatihan penulisan artikel ilmiah bagi mahasiswa dengan tujuan memberikan pengetahuan dan pemahaman (edukasi) serta melatih keterampilan  menulis artikel ilmiah dengan baik agar menghasilkan publikasi ilmiah yang berkualitas serta bermanfaat. Kegiatan pelatihan penulisan artikel ilmiah bagi mahasiswa tingkat akhir di Politeknik Yakpermas Banyumas diselenggarakan dalam 2 hari. Hari pertama yaitu penyampaian materi tentang artikel ilmiah, kemudian dilanjutkan hari kedua yaitu asistensi penulisan artikel ilmiah. Pelatihan ini diikuti oleh 85 mahasiswa tingkat akhir yang berasal dari tiga program studi yaitu D-III Keperawatan, D-III Rekam Medis dan Informasi Kesehatan, dan D-IV Teknologi Laboratorium Medis. Sebanyak 5 orang peserta dengan artikel ilmiah terbaik diberikan apresiasi berupa penerbitan artikel pada Journal of Nursing and Health.

Panti Wreda Catur Nugraha di Kabupaten Banyumas merupakan lembaga sosial yang merawat sekitar 30 lansia dengan berbagai kondisi kesehatan. Pencatatan rekam medis yang masih dilakukan secara manual menyebabkan data rawan hilang, sulit dianalisis, dan kurang efisien. Tim Pengabdian kepada Masyarakat dari STIKOM Yos Sudarso Purwokerto menyelenggarakan pelatihan pembuatan laporan rekam medis berbasis digital dengan memanfaatkan Google Forms untuk pengumpulan data dan Microsoft Word untuk penyusunan laporan. Kegiatan ini diikuti oleh 20 pengasuh dan karyawan panti. Metode yang digunakan meliputi penyuluhan, demonstrasi, praktik langsung, serta evaluasi melalui pre-test dan post-test. Hasil pelatihan menunjukkan adanya peningkatan kemampuan peserta dalam menggunakan komputer, terbukti dari kenaikan nilai rata-rata dari 47 pada pre-test menjadi 60,5 pada post-test, dengan dua peserta mencapai nilai sempurna. Pelatihan ini berhasil meningkatkan literasi digital peserta dan diharapkan dapat diterapkan secara berkelanjutan untuk mendukung peningkatan mutu dokumentasi kesehatan lansia di Panti Wreda Catur Nugraha.

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.

Electronic Medical Records (EMR) are medical records compiled and stored through an electronic system used to support the provision of healthcare services. The implementation of EMR facilitates faster, more practical, and integrated patient data recording. Electronic Medical Records (EMR) are designed to improve the efficiency, accessibility, and accuracy of patient information within healthcare institutions. This study used a qualitative descriptive approach with a case study design through interviews to assess the readiness of EMR implementation in terms of the 5M management aspects (Man, Money, Material, Machine, Method) at Muhammadiyah General Hospital, Ponorogo Regency. The study sample consisted of 27 healthcare workers selected using a purposive sampling technique. The case study design allowed researchers to capture in-depth insights from healthcare workers directly involved in EMR implementation. The results showed that from the Man element, most healthcare workers were ready to use EMR, as indicated by their comfort and skills in operating the application. In the Money element, there is a system maintenance budget and support for EMR development in the inpatient unit and the Emergency Room. The Material element indicates the availability of adequate software, while the Machine element includes computer devices, internet connections, and a stable server to support users. These technological resources ensure a user-friendly and reliable system. The final element, Method, is demonstrated by the existence of clear SOPs and workflows, enabling healthcare workers to understand and effectively follow the EMR implementation process. Overall, the findings indicate that the hospital is institutionally prepared for EMR adoption.    

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.

Minister of Health Regulation No. 269 of 2008 explains that medical records are defined as a collection of documents containing complete information regarding patient identity, examination results, therapy, medical procedures, and health services received. In working, an employee should be able to balance their workload to achieve work harmony that contributes to increased productivity. Job satisfaction reflects the appreciation and comfort felt by an individual for the tasks they perform. Conversely, dissatisfaction at work can trigger negative reactions in the form of aggressive behavior or a tendency to withdraw from social interactions around them. Job satisfaction also greatly influences employee motivation and commitment to continue working with enthusiasm and achieve the desired goals. The purpose of this study was to determine the relationship between workload and job satisfaction with employee performance in the Medical Records Installation of Cut Meutia Hospital, Lhokseumawe in 2023. The research method was an analytical survey with a cross-sectional approach. The study was conducted at Cut Meutia Hospital, Lhokseumawe from September to December 2023. The study population was 40 Medical Records Installation employees. The sampling technique used total sampling, namely 40 respondents. Data analysis used univariate analysis and bivariate analysis. The results of the study based on the chi-square test showed a relationship between workload and employee performance at the Medical Records Installation of Cut Meutia Hospital, Lhokseumawe with a p-value = 0.001 <0.05 and a relationship between job satisfaction and employee performance at the Medical Records Installation of Cut Meutia Hospital, Lhokseumawe with a p-value = 0.000 <0.05. Conclusion; The conclusion in the study is that there is a relationship between workload and job satisfaction with employee performance at the Medical Records Installation of Cut Meutia Hospital, Lhokseumawe in 2023.