EVALUASI KELENGKAPAN PENGISIAN REKAM MEDIS ELEKTRONIK SEBELUM DAN SESUDAH PELATIHAN TENAGA MEDIS GUNA MENINGKATKAN MUTU DI RSUD OTO ISKANDAR DI NATA

Abstract

The implementation of Electronic Medical Records (EMR) has been mandatory for healthcare facilities in Indonesia since the issuance of Minister of Health Regulation Number 24 of 2022; however, compliance regarding clinical data entry in various hospitals still shows suboptimal levels of completeness. This study aimed to assess the impact of medical staff training on the accuracy and completeness of EMR entries for inpatients at Oto Iskandar Di Nata Regional General Hospital (RSUD) in Bandung Regency. A descriptive quantitative design was employed, utilizing a document observation approach with a checklist. The sample size was determined using Slovin's formula based on a population of 10,888 inpatient EMR files from the period of October 2025 to March 2026; a total of 100 files were selected via consecutive sampling, comprising 52 files from the pre-training period and 48 files from the post-training period. The findings revealed that the average EMR completeness rate was 72.65% (range: 60%–85%) before training and 71.17% (range: 62%–80%) after training, representing a decrease of 1.48%. These results indicate that the training conducted did not improve the quality of EMR documentation; this is likely attributable to the novelty of the system, incomplete dissemination of information, a lack of routine monitoring and evaluation, ingrained user habits, and the heavy workload borne by medical staff.