ANALYSIS OF THE COMPLETENESS OF OUTPATIENT MEDICAL RESUMES ON THE QUALITY OF ELECTRONIC MEDICAL RECORDS

Erix Gunawan; Febria Merssy

Erix Gunawan Politeknik Piksi Ganesha
Febria Merssy Politeknik Piksi Ganesha

Keywords: medical resume, electronic medical record, completeness, outpatient, 1erix.gunawan@piksi.ac.id

Abstract

Electronic Medical Records (EMR) are medical records that are managed with an electronic system in place of paper documents. The purpose of this study is to measure the level of completeness of outpatient medical resume content and its relationship with the quality of the Electronic Medical Record (EMR) system in health facilities. Descriptive quantitative is the method used in this study with a cross-sectional approach. Overall, this study showed the results of complete medical resumes with a percentage of 31% and incomplete of 69%. The most often incomplete components are the Suggestion and Patient’s/Proxy Signature components. Thus, it can be concluded that the use of the Electronic Medical Record (EMR) system in this case does not fully guarantee the completeness of the data.