Electronic-Based Medical Records Auditing System in Indonesian Hospital: Development and Trials

Abstract

Medical records must be made and completed
immediately after the patient receives the health services.
To maintain the quality of medical records, medical
records must be documented completely. Checking the
medical record completeness can be done using medical
record analysis or audit techniques. During this time,
the audit process of medical records in hospitals is still
largely carried out conventionally or manually. The
increasing use of information technology in the health
sector has encouraged Yogyakarta City General Hospital
to develop and use an electronic applications for medical
audit activities, particularly in relation to the incomplete
of medical records. This study aimed to design a prototype
of an electronic-based medical record review system
in Yogyakarta City General Hospital. This study used
a research and development method with prototyping
approach. The research was carried out starting from
qualitative data collection by observations, interviews,
focus group discussion, and documentation study. The
design process uses a prototyping scheme by involving
the medical records officers as research subjects. The
prototype of a web-based electronic medical record review
system has been developed and has been evaluated. The
results in the aspects of system usefulness, information
quality, and interface quality shows that 66.77% of
respondents feeling satisfied with the prototype that has
been developed. The prototype that has been developed
needs to be further evaluated so that user needs and
compliance with standards relating to medical record
review can be accommodated properly.