(KTI) OVERVIEW OF THE DOCUMENTATION SYSTEM AND CONFIDENTIALITY OF ELECTRONIC MEDICAL RECORDS (EMR) AT RSUD ARJAWINANGUN

Health services in hospitals must be recorded and documented through medical
records. This documentation includes the history of illness, treatment, and actions given to
patients by health workers. Along with the development of digital technology, the
digitalization transformation of health services demands the use of electronic medical
records that are secure and maintain data confidentiality. This is to protect information
from interference from unauthorized internal and external parties, so that data in electronic
medical records is protected from unauthorized use and dissemination. The purpose of this
study was to determine the description of the documentation system and confidentiality of
electronic medical records at Arjawinangun Hospital.
This type of research uses descriptive methods. The object of this research is the
documentation and confidentiality of electronic medical records. The subjects in this study
were nurses and IT officers. The instruments in this study used observation sheets.
The results showed that electronic medical record documentation was timely in
accordance with the patient's examination time. However, evaluation of accuracy and
completeness is not carried out regularly. Electronic signatures to certify medical
information have not been facilitated for patients and other medical personnel. Policies on
RME filling are also not yet in place. Confidentiality of electronic medical records is
implemented through a username and password for each officer before logging into the
RME system. The input of administrative and clinical patient data is carried out according
to the authority of each field. Data correction is only carried out if there is an error in
inputting, with a repair time limit of around 1x24 hours from the time the data is inputted.
However, data correction can be done without approval from the authorized party, even if
it exceeds the given deadline. Access to view data in the patient's electronic medical record
is only allowed for authorized parties. It is expected that hospitals establish a policy for
filling electronic medical records as a legal basis in case of irregularities and an access
restriction policy should be established to prevent unauthorised users from operating
electronic medical record applications to protect patient data.
Keywords : Documentation, Confidentiality, Electronic Medical Records
References : 26 (2013 - 2024)