Factors Associated with Completeness and Accuracy of Electronic Medical Record Entry in Community Health Center in Yogyakarta


Harinto Nur Seha1,2), Didik Tamtomo3), Endang Sutisna Sulaeman4)

 

1)Medical Record and Health Information, School of Health Polytechnics

Permata Indonesia, Yogyakarta

2)Masters Program in Public Health, Universitas Sebelas Maret

3)Faculty of medicine, Universitas Sebelas Maret

4)Department of Public Health, Faculty of Medicine, Universitas Sebelas Maret

 

ABSTRACT

Background: The implementation of electronic patient records in primary care is a key objective of many health care systems, including Indonesia. This reflects a gro­­wing recognition of the potential benefits of electronic records on the safety, qua­lity and efficiency of healthcare. Documentation in the medical record is expected to be complete, accurate, concise, and timed/dated. This study aimed to analyze factors associated with completeness and accuracy of electronic medical record entry in community health center in Yogyakarta.

Subjects and Method: This was an analytic observational study with a cross-sectional design. The study was conducted in 25 community health cen­ters in Yogyakarta, from March to June 2018. A sample of 200 patient me­di­cal records was selected by simple random sampling. The dependent variables were completeness and accuracy of medical record. The independent variables were tenure, multi task, and accreditation status of puskesmas. The data were col­lected by questionnaire and analyzed by a multiple logistic regression.

Results: Completeness of electronic medical record was positively associated with longer tenure (b= 0.58; 95% CI= 0.10 to 1.05; p=0.018), but negatively asso­ciated with multiple task occupation (b= -2.12; 95% CI= -3.44 to -0.81; p= 0.002). Accuracy of electronic medical record was positively associated with lo­nger tenure (b= 1.10; 95% CI= 0.34 to 1.85; p= 0.005), but negatively associated with mul­tiple task occupation (b= -4.20; 95% CI= -6.30 to -2.11; p<0.001). Accre­di­­ta­tion status of puskesmas did not affect completeness and accuracy.

Conclusion: Completeness and accuracy of electronic medical record are posi­ti­v­ely associated with longer tenure, but negatively associated with multiple task occu­pation. Accreditation status of puskesmas does not affect completeness and accu­racy.

Keywords: electronic medical record, completeness, accuracy, tenure, occupation, community health center

Correspondence: Harinto Nur Seha. Medical Record and Health Information, School of Health Polytechnics Permata Indonesia, Yogyakarta. Email: harinto_ns@permataindonesia.ac.id. Mobile: +62 85749724513

DOI: https://doi.org/10.26911/theicph.2018.02.44

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