Kajian Implementasi Variabel dan Metadata Rekam Medis Elektronik Rawat Jalan di Rumah Sakit PWS

Saryadi Saryadi; Aditya Kurniawan; Nopita Cahyaningsih; Novi Arintya Putri Admaja

doi:10.59603/niantanasikka.v4i3.1454

Authors

Saryadi Saryadi Universitas Duta Bangsa Surakarta
Aditya Kurniawan Universitas Duta Bangsa Surakarta
Nopita Cahyaningsih Universitas Duta Bangsa Surakarta
Novi Arintya Putri Admaja Universitas Duta Bangsa Surakarta

DOI:

https://doi.org/10.59603/niantanasikka.v4i3.1454

Keywords:

Data Variables, Electronic Medical Records, Health Data Interoperability, Hospital Information Management System, Metadata

Abstract

PWS Hospital implemented an Electronic Medical Record (EMR) system on December 5, 2022, across outpatient services. This study aims to assess compliance of variables and metadata in the outpatient EMR system with the standards of Minister of Health Decree Number HK.01.07/MENKES/1423/2022. A quantitative descriptive method with a cross-sectional approach was employed, covering six outpatient EMR forms: general patient identity, newborn identity, payment method, general consent, initial outpatient assessment, and specialist examination. The results show varying compliance for variables: general patient identity (92%), newborn identity (83%), initial outpatient assessment (95%), and specialist examination (59%), while payment method and general consent showed 0% compliance. Metadata compliance reached 84% for general patient identity, 67% for newborn identity, 67% for initial outpatient assessment, and 56% for specialist examination, whereas payment method and general consent recorded 0%. These discrepancies were attributed to incomplete system transition, HMIS development limitations, differences between operational needs and national standards, and incomplete integration of clinical forms. Hospital management should accelerate data structure adjustments, integrate all clinical forms, and conduct periodic system evaluation and development to support health data interoperability.

References

Act, A. R., & Ion, I. N. T. R. O. (2026). Effectiveness of electronic medical records implementation in outpatient services: A qualitative study at Dr. T. C. Hillers Hospital, Maumere. Journal of Health and Medical Science, 6(1), 2799–2810. https://doi.org/10.31004/joecy.v6i1.6712

Agustin, R. (2023). Analisis kesesuaian variabel dan metadata pada lembar identitas rekam medis elektronik. Jurnal Manajemen Informasi Kesehatan, 11(2), 45–52.

Albagmi, S. (2021). The effectiveness of EMR implementation regarding reducing documentation errors and waiting time for patients in outpatient clinics: A systematic review. F1000Research, 10, 1–17. https://doi.org/10.12688/f1000research.45039.2

Andriani, D., Sari, M., & Wibowo, A. (2025). Evaluasi penerapan variabel dan metadata rekam medis elektronik pelayanan rawat jalan berdasarkan regulasi SATUSEHAT. Jurnal Rekam Medis dan Informasi Kesehatan, 14(1), 12–20.

Andriani, R., Pertiwi, J., Alfitasari, A., Salima, T. A. R., & Wijayanti, T. (2025). Variabel dan metadata rekam medis elektronik sebagai standar interoperabilitas data kesehatan di rumah sakit. Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda, 10(2), 230–239. https://doi.org/10.52943/jipiki.v10i2.1946

Asri, D. I., & Budi, S. C. (2025). Evaluation of electronic medical records implementation in outpatient services at the hospital using MMUST framework. Journal of Health Information Management, 6(3), 193–204. https://doi.org/10.31101/ijhst.v6i3.3897

Darsono, D. (2024). Evaluasi rekam medis elektronik RS Bethesda Yogyakarta dalam upaya mendukung percepatan transformasi kesehatan digital. Journal of Information Systems for Public Health, 9(1), 20–30. https://doi.org/10.22146/jisph.91784

Fatmasari, A. (2024). Hospital readiness to implement electronic medical records: A systematic literature review. Jurnal ARSI: Administrasi Rumah Sakit Indonesia, 10(3). https://doi.org/10.7454/arsi.v10i3.1189

Feri, A., Rendi, S., & Sinanto, A. (2025). Evaluasi metadata rekam medis elektronik rawat jalan. Jurnal Rekam Medis dan Manajemen Informasi Kesehatan, 4, 1–14. https://doi.org/10.47134/inhis.v4i2.79

Harsiwi, T., Insani, N., Wikansari, N., & Febrian, E. (2024). Electronic medical record: Challenges in terms of management elements related to the implementation of inpatient electronic medical records. Journal of Healthcare Administration, 6(24), 163–167.

Hossain, K., Sutanto, J., Handayani, P. W., & Haryanto, A. A. (2025). An exploratory study of electronic medical record implementation and recordkeeping culture: The case of hospitals in Indonesia. BMC Health Services Research, 25, Article 12399. https://doi.org/10.1186/s12913-025-12399-0

Id, A. D. B., Lettieri, E., & Gastaldi, L. (2020). Electronic medical records implementation in hospital: An empirical investigation of individual and organizational determinants. PLOS ONE, 15(6), 1–12. https://doi.org/10.1371/journal.pone.0234108

Ilyas, A. A., Golo, Z. A., Retnowati, R., & Saputra, J. D. (2023). Analisis kesesuaian variabel dan meta data rekam medis elektronik: Studi kasus pada instalasi rawat jalan Rumah Sakit X. Jurnal Rekam Medis dan Informasi Kesehatan, 6(2), 89–97. https://doi.org/10.31983/jrmik.v6i2.10640

Ilyas, M., Santoso, B., & Rahmawati, E. (2023). Implementasi dan kendala penerapan variabel general consent pada rekam medis elektronik. Jurnal Kesehatan Digital Indonesia, 4(3), 110–118.

Irawan, D., & Gunawan, E. (2024). Evaluasi implementasi rekam medis elektronik rawat jalan di Rumah Sakit Umum Daerah Cililin tahun 2024. PREPOTIF: Jurnal Kesehatan Masyarakat, 8(2), 3919–3923. https://doi.org/10.31004/prepotif.v8i2.32233

Journal, M., Br, E., Butar, B., Pradita, R., & Bros, U. A. (2026). Analysis of variable standardization and meta data of electronic medical records at Santa Elisabeth Batam Hospital. Journal of Medical Record Analytics, 1(2), 1–8.

Kementerian Kesehatan Republik Indonesia. (2022). Keputusan Menteri Kesehatan Nomor HK.01.07/Menkes/1423/2022 tentang pedoman variabel dan metadata pada penyelenggaraan rekam medis elektronik. Kementerian Kesehatan Republik Indonesia.

Kurniawan, D. S. (2025). Innovations for successful electronic medical records (EMR) implementation in hospitals. Indonesian Journal of Innovation Studies, 26(2), 1–11. https://doi.org/10.21070/ijins.v26i2.1360

Luh, N., Arum, P., Ati, P., Basabih, M., Najah, M., & S, M. A. (2024). Digital transformation: Challenges and implementation electronic medical record system in Indonesia. Journal of Health Policy and Digitalization, 11(1), 1–11. https://doi.org/10.20527/jpkmi.v11i1.18709

Melisa, N. P., Sukmaningsih, W. R., & Licia, R. (2024). Analisis rekam medis elektronik rawat jalan pada aspek keamanan data pasien di Rumah Sakit Umum Daerah Dr. Soediran Mangun Sumarso Wonogiri. Jurnal Manajemen Informasi Kesehatan, 3(3), 160–168. https://doi.org/10.46808/jhimi.v3i3.193

Menteri Kesehatan Republik Indonesia. (2022). Peraturan Menteri Kesehatan Nomor 24 Tahun 2022 tentang rekam medis. Kementerian Kesehatan Republik Indonesia.

Nor, W., Binti, S., Hashim, W., Binti, F., Aida, J., & Binti, N. (2024). The implementation of electronic medical record (EMR) in hospitals: A conceptual study. Journal of Health Informatics, 16(2), 688–695.

Nugraha, A. P., Kurniawan, R., & Saputra, D. (2023). Efektivitas implementasi rekam medis elektronik terhadap efisiensi waktu pelayanan klinis di rumah sakit. Jurnal Administrasi Rumah Sakit Indonesia, 9(2), 88–95.

Pratama, F. A., & Hidayat, T. (2024). Analisis interoperabilitas dan redudansi data pada integrasi sistem rekam medis elektronik rumah sakit. Jurnal Informatika dan Sistem Kesehatan, 7(1), 33–41.

Rosalinda, R., Setiatin, S., & Susanto, A. (2021). Evaluasi penerapan rekam medis elektronik rawat jalan di Rumah Sakit Umum X Bandung tahun 2021. Jurnal Manajemen Informasi Kesehatan Indonesia, 1(8), 1045–1056. https://doi.org/10.59141/cerdika.v1i8.135

Rosita, R., Risqika, A. M., Yuliani, N., Luh, N., & Devhy, P. (2024). Evaluation of the implementation of outpatient electronic medical records. Health Information System Journal, 6, 184–188.

Rusdiana, E., & Sanjaya, G. Y. (2024). Tantangan penerapan rekam medis elektronik untuk unit rawat. Jurnal Manajemen Pelayanan Kesehatan, 27(3), 103–109. https://doi.org/10.22146/jmpk.v27i3.15871

Sakit, R., & Waluya, P. (2022). Evaluasi penerapan rekam medis elektronik di unit rawat jalan Rumah Sakit Panti Waluya Malang. Rumah Sakit Panti Waluya.

Seha, H. N., Noor, A. Y., Damayanti, A. L., & Permata, P. (2024). Interoperability-driven design: Analyzing core metadata and variables for dental electronic medical records. Journal of Healthcare Engineering, 14(2). https://doi.org/10.47709/elektriese.v14i02.5515

Sutha, D. W., Masyfufah, L., Faida, E. W., & Wahyuni, T. (2025). The impact of use of electronic medical records on the quality of health services and patient safety: Review. Journal of Health Science and Safety, 3(1), 1–11. https://doi.org/10.47134/ijhis.v3i1.62

Torkman, R., & Ghapanchi, A. H. (2025). Exploring healthcare professionals' perspectives on electronic medical records: A qualitative study. Health Information Management Journal, 1–28. https://doi.org/10.3390/info16030236

Uktuvia, A., Az-zahra, E., Aditya, M. I., & Sari, N. I. (2024). Success and impact factors of the implementation of electronic medical records in hospitals: Literature review. Journal of Health Management Review, 15, 1–12. https://doi.org/10.55129/jnerscommunity.v15i1.3147

Wulandari, S., & Susanto, A. (2024). Tantangan standarisasi variabel rekam medis elektronik dalam pertukaran informasi kesehatan terintegrasi: Systematic literature review. Jurnal Kesehatan Masyarakat dan Manajemen Rumah Sakit, 6(2), 140–149.

Xu, N., Badwaik, I., Lee, G., & Ford, E. W. (2025). Trends in electronic health record metadata use for management purposes. Learning Health Systems, 1–8. https://doi.org/10.1002/lrh2.70001