Analysis of completeness factors for filling inpatient discharge summaries H. Hanafie regional hospital Muara Bungo Jambi 2024

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Published Jun 10, 2025
https://doi.org/10.35335/midwifery.v13i2.1953
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Vol. 13 No. 2 (2025): June: Health Sciences and related fields

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Veita Astrianda
Politeknik Indonusa Surakarta, Indonesia
Wahyu Ratri Sukmaningsih
Politeknik Indonusa Surakarta, Indonesia

Abstract

Although the discharge summary is essential for ensuring continuity of patient care, supporting clinical decision-making, and enabling administrative processes such as BPJS insurance claims, RSUD H. Hanafie Muara Bungo continues to face challenges in achieving complete and standardized medical documentation. This study analyzes the factors influencing the completeness of inpatient medical resumes at RSUD H. Hanafie using the 5M framework: Man, Method, Machine, Material, and Money. A qualitative descriptive approach was employed, with data collected through document review, observation, and interviews with Responsible Doctors (DPJP) and the Head of the Medical Records Installation. A total of 100 medical resumes were selected using simple random sampling, based on the Slovin formula with a 10% margin of error. Data were analyzed through data reduction, presentation, conclusion drawing, and validation using triangulation. Results showed that the patient identification component achieved 100% completeness, while important reporting, authentication, and recording reached 98%, 95%, and 77%, respectively. Key influencing factors included limited routine training and discipline (Man), absence of SOPs and weak monitoring (Method), suboptimal form design (Material), insufficient devices and system disruptions (Machine), and budget constraints (Money). To address these issues, a comprehensive strategy involving health worker collaboration, system support, and strong management commitment is essential to ensure that the clinical, legal, and administrative functions of medical resumes are fulfilled.

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How to Cite
Astrianda, V. and Sukmaningsih, W. R. (2025) “Analysis of completeness factors for filling inpatient discharge summaries H. Hanafie regional hospital Muara Bungo Jambi 2024”, Science Midwifery, 13(2), pp. 519-527. doi: 10.35335/midwifery.v13i2.1953.

References

Alami, H., Rivard, L., Lehoux, P., Hoffman, S. J., & Cadeddu, S. B. (2021). Digital health at the age of equity: Insights from health system stakeholders in low-resource settings. Journal of Medical Internet Research, 23(4), 24861. https://doi.org/10.2196/24861
Andayani, T. R., Supriyadi, E., & Hermawan, F. (2022). The impact of human factors on electronic medical record completion: A case study in Indonesian hospitals. Asia Pacific Journal of Health Management, 17(1), 22–30. https://doi.org/10.24083/apjhm.v17i1.1434
Creswell, J. W., & Poth, C. N. (2018). Qualitative inquiry and research design: Choosing among five approaches (4th ed.). Sage Publications.
Gunawan, D., & Herlina, M. (2023). User experience barriers in electronic medical record systems: A usability study in urban hospitals. Journal of Health Informatics in Developing Countries, 17(1), 85–93. https://doi.org/10.12827/jhidc.v17i1.365
Halimatusaadah, H., & Hidayati, M. (2022). Kualitas pengisian resume medis dan dampaknya terhadap proses klaim BPJS. Jurnal Manajemen Rumah Sakit Indonesia, 10(2), 115–123.
Hidayat, R., & Sihombing, R. (2023). Strengthening compliance in electronic documentation: The role of audit and feedback in public hospitals. BMC Medical Informatics and Decision Making, 23(1), 104. https://doi.org/10.1186/s12911-023-02107-y
Kemenkes RI. (2020). Peraturan Menteri Kesehatan Nomor 30 Tahun 2020 tentang Klasifikasi dan Perizinan Rumah Sakit. 3, 1–80.
Lee, S., & Park, H. (2022). Impact of interface complexity in electronic health record systems on documentation behavior among clinicians. International Journal of Medical Informatics, 162, 104752. https://doi.org/10.1016/j.ijmedinf.2022.104752
Lestari, D. M., Nugroho, H., & Putri, R. (2022). Institutional factors affecting medical record completeness in Indonesian hospitals. Journal of Health Information Management, 14(1), 23–30. https://doi.org/10.1016/j.jhim.2022.01.004
Mathar, M., & Igayanti, L. (2021). The importance of discharge summaries in continuity of patient care: A review of best practices. Global Health Documentation Journal, 14(1), 33–47.
Miles, M. B., & Huberman, A. M. (1994). Qualitative data analysis (An expande).
Rahmah, N., & Astuti, E. S. (2020). Evaluasi kelengkapan pengisian resume medis pasien rawat inap di rumah sakit. Jurnal Manajemen Informasi Kesehatan Indonesia, 8(1), 45–53.
Rosman, A. R., Dewi, F. S., & Kurniawan, D. (2023). Barriers to the adoption of electronic medical records in Indonesian hospitals: A mixed-method study. Health Informatics Journal, 29(1), 146–160. https://doi.org/10.1177/14604582231101682
Santoso, A., & Wijaya, R. (2023). Barriers to effective electronic documentation in hospital settings: A qualitative study. International Journal of Medical Informatics, 169, 104957. https://doi.org/10.1016/j.ijmedinf.2023.104957
Setiawan, A., Kurniawan, R., & Pramudito, H. (2021). Implementasi sistem rekam medis elektronik terhadap peningkatan kualitas dokumentasi identitas pasien. Jurnal Sistem Informasi Kesehatan, 9(2), 102–110.
Setiawan, A., Rachman, A., & Yusuf, M. (2021). Evaluating the design of electronic medical resume forms and its impact on physician compliance. Indonesian Journal of Health System Research, 15(3), 141–150.
Sharma, R., Gupta, A., & Mehra, N. (2022). Enhancing clinician efficiency through digital form redesign: Evidence from a multi-center study. Journal of Biomedical Informatics, 132, 104134. https://doi.org/10.1016/j.jbi.2022.104134
Siregar, A. Y. M., & Wardhani, N. M. (2020). The role of financial resources in sustaining health information systems: A case study of EMR implementation in public hospitals. Journal of Health Policy and Management, 5(2), 78–86.
Siregar, F., & Wardhani, R. (2020). Pengaruh dukungan anggaran terhadap keberhasilan implementasi sistem informasi kesehatan di rumah sakit. Jurnal Sistem Informasi Kesehatan, 8(2), 89–97.
Sugiyono. (2014). Metode penelitian bisnis: pendekatan kuantitatif, kualitatif, kombinasi, dan R&D. Alfabeta.
Susanti, R., & Amalia, D. (2021). Pengaruh pelatihan terhadap kelengkapan dan ketepatan pengisian resume medis oleh tenaga kesehatan. Jurnal Manajemen Informasi Kesehatan, 7(1), 55–63.
Trianto, A., & Rohaeni, H. (2021). The role of electronic discharge summaries in improving patient care coordination. Health Informatics Journal, 17(3), 122–135.
Tubaishat, A. (2022). Exploring budget allocation challenges in EMR adoption: A multi-country perspective. BMC Health Services Research, 22(1), 956. https://doi.org/10.1186/s12913-022-08217-3
Wibowo, H., & Kurniawati, D. (2020). Hubungan frekuensi pelatihan dengan kepatuhan dokter dalam pengisian resume medis elektronik. Jurnal Rekam Medis Dan Informasi Kesehatan, 10(2), 87–94.
Wijayanti, D., & Permana, A. (2022). Physician workload and its effect on medical record completion in resource-limited settings. Journal of Hospital Administration, 11(2), 58–67. https://doi.org/10.5430/jha.v11n2p58
Wirajaya, I. K. (2019). Faktor-faktor yang mempengaruhi kelengkapan rekam medis di rumah sakit daerah. Jurnal Informasi Kesehatan Indonesia, 6(3), 55–63.
Wulandari, S., & Prasetyo, A. (2020). Evaluation of discipline in electronic medical record documentation among healthcare providers. Health Services Journal of Indonesia, 12(2), 44–51.
Yuliana, S., & Hendrawan, D. (2021). Pengaruh sistem informasi rumah sakit terhadap kelengkapan data rekam medis pasien. Jurnal Administrasi Rumah Sakit Indonesia, 11(1), 22–29.