Peningkatan Pemahaman Standar Pendokumentasian Rekam Medis Elektronik melalui Kegiatan Edukasi bagi Pemberi Asuhan Profesional di RS St. Carolus Jakarta

Anastasia Cyntia Dewi Kurniawati; Witri Zuama Qomarania; Husni Abdul Muchlis; Imam Sutanto; Nungky Nurkasih Kendrastuti

doi:10.53863/abdibaraya.v5i01.2294

Authors

Anastasia Cyntia Dewi Kurniawati Universitas Esa Unggul, Jakarta, Indonesia
Witri Zuama Qomarania Universitas Esa Unggul, Jakarta, Indonesia
Husni Abdul Muchlis Universitas Esa Unggul, Jakarta, Indonesia
Imam Sutanto Universitas Esa Unggul, Jakarta, Indonesia
Nungky Nurkasih Kendrastuti Universitas Esa Unggul, Jakarta, Indonesia

DOI:

https://doi.org/10.53863/abdibaraya.v5i01.2294

Keywords:

Electronic Medical Records; Clinical Documentation; Healthcare Professionals’ Understanding; Quality of Care; Hospital Accreditation

Abstract

The implementation of Electronic Medical Records (EMR) is an important component of digital transformation in healthcare services aimed at improving service quality, patient safety, and hospital accreditation compliance. St. Carolus Hospital Jakarta has implemented EMR since 2019; however, several documentation-related issues remain, including inconsistencies in Integrated Patient Progress Notes (CPPT), delays in medical discharge summaries, and variations in documentation practices among healthcare professionals. This community service program aimed to enhance healthcare professionals’ understanding of standards for complete, accurate, and timely documentation of medical and electronic medical records in accordance with regulations and hospital accreditation standards. The program was held on February 27, 2026, at St. Carolus Hospital in Jakarta and included 32 participants, comprising physicians, nurses, medical record professionals, pharmacists, and other healthcare workers. The intervention was delivered through educational sessions, discussions on quality indicators and accreditation standards related to clinical documentation, and interactive discussions with resource persons. Evaluation was conducted using a 14-item multiple-choice pre-test and post-test questionnaire. The results demonstrated an increase in participants’ understanding, with a mean pre-test score of 0.911 ± 0.082 and a mean post-test score of 0.990 ± 0.025. Wilcoxon Signed-Rank Test analysis showed a statistically significant difference between pre-test and post-test scores (p < 0.001), with an effect size of 0.913, indicating a very large effect. The program was effective in strengthening participants’ understanding and aligning perceptions regarding medical record and electronic medical record documentation standards. It is expected to improve the quality of clinical documentation, healthcare services, and patient safety, as well as compliance with hospital accreditation standards. medical record documentation, positively impacting service quality and hospital accreditation readiness.

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