The provision medical records quality cannot be separated from consistent recording in the use of medical symbols and abbreviations.. Symbols and abbreviations have been regulated in SNARS Edition 1.1. The uniform use of medical symbols and abbreviations aims to make the writing of terms understandable and can be used as a communication tool between health workers. Hospitals must have regulations, regarding the symbols and abbreviations used. Based on the results of preliminary studies at PKU Muhammadiyah Gamping Hospital, monitoring and evaluation have never been carried out regarding the use of symbols and abbreviations. Research on the accuracy of the use of symbols and abbreviations has also never been done, so it is necessary to conduct a review of the problem. This study used descriptive observational method with quantitative approach and cross sectional design. A purposive sampling technique used to 100 samples on the emergency room form for inpatients in the first quarter of 2022. The results showed that there was no monitoring and evaluation related to the use of symbols and abbreviations at PKU Muhammadiyah Gamping Hospital. The percentage of correct use of symbols was 27% and the percentage of correct use of abbreviations was 37%. The results of the analysis show that the inaccurate use of medical symbols and abbreviations is caused by the lack of socialization to related health workers, and there is non-compliance with officers in using medical symbols and abbreviations that have been regulated in the applicable guidelines at PKU Muhammadiyah Gamping Hospital.

The digitalization of health services is developing very rapidly, marked by the existence of electronic medical records. The implementation of electronic medical records has been required by the government in Minister of Health Regulation number 24 of 2022. Based on the results of a preliminary study at the Berbah Sleman Primary Health Center, there were several obstacles to its implementation, namely related to the internet network and errors in the software which caused the outpatient registration process is stopped. The object of this research is to describe the perceptions of users of outpatient electronic medical records from the perspective of the Technology Acceptance Model (TAM). This type of research is quantitative descriptive by distributing questionnaires to 18 respondents. The results obtained showed that 15 respondents (83%) said it was very good in terms of perceived usefulness, 10 respondents (56%) said it was very easy in terms of perceived ease of use, 18 respondents (100%) said it was very good in terms of perceived behavior intention to use, and as many as 16 respondents (89%) stated that it was very good in terms of actual usage perception. Of the four perceptions which include usefulness, ease of use, behavior intention to use, and actual usage in implementing electronic medical records, users receive it very well.

Penyelenggaran rekam medis yang baik tidak lepas dari pencatatan yang konsisten dalam penggunaan simbol maupun singkatan medis. Simbol dan singkatan sudah diatur dalam SNARS Edition 1.1. Penyeragaman penggunaan simbol dan singkatan medis tujuannya adalah agar penulisan istilah dapat dipahami dan dapat digunakan sebagai alat komunikasi antar tenaga kesehatan. Rumah sakit harus memiliki regulasi terkait simbol maupun singkatan yang digunakan. Berdasarkan hasil studi pendahuluan di RS PKU Muhammadiyah Gamping belum pernah dilakukan monitoring dan evaluasi terkait penggunaan simbol dan singkatan. Penelitian mengenai ketepatan penggunaan simbol dan singkatan juga belum pernah dilakukan, sehingga perlu dilakukan peninjauan terkait masalah tersebut. Penelitian ini menggunakan metode deskriptif observasional dengan pendekatan kuantitatif dan rancangan cross sectional. Teknik purposive sampling dilakukan terhadap 100 sampel pada formulir IGD pasien rawat inap triwulan I tahun 2022. Hasil penelitian menunjukkan bahwa belum adanya monitoring dan evaluasi terkait penggunaan simbol dan singkatan di RS PKU Muhammadiyah Gamping. Persentase ketepatan penggunaan simbol sebesar 27% dan persentase ketepatan penggunaan singkatan sebesar 37%. Hasil analisis menunjukkan bahwa ketidaktepatan penggunaan simbol dan singkatan medis disebabkan oleh kurangnya sosialisasi kepada tenaga kesehatan terkait, serta terdapat ketidakpatuhan petugas dalam menggunakan simbol dan singkatan medis yang telah diatur dalam buku pedoman yang berlaku di RS PKU Muhammadiyah Gamping.