(KTI) ANALYSIS OF COMPLETENESS OF ELECTRONIC MEDICAL RECORD FILLING OF OUTPATIENT PATIENTS AT CANGKOL COMMUNITY HEALTH CENTER CIREBON CITY

Electronic Medical Records (EMR) play a crucial role in delivering quality
healthcare services. The completeness of EMR documentation supports the
continuity of patient information, serves as legal evidence, and ensures service
quality. This study aims to analyze the completeness of outpatient EMR
documentation at Cangkol Community Health Center, Cirebon City. The research
employed a descriptive quantitative method using simple random sampling on 94
EMR samples from April 2025. Data collection instruments included an
observation checklist covering three main aspects: patient identification, clinical
documentation, and authentication.
The results showed that, in the identification aspect, items such as patient name,
medical record number, address, gender, and education were 100% complete.
However, the completeness of date of birth and occupation was relatively low, at
75% and 86% respectively. In the clinical documentation aspect, all items such as
anamnesis, supporting examinations, and diagnosis were fully complete, except for
informed consent, which was only 73% complete. In the authentication aspect, the
date and name of the examiner were 100% complete, while examiner signatures
were found in only 32% of the records.
In conclusion, the completeness of EMR documentation at Cangkol Health Center
has not yet met the 100% standard as required by the Ministry of Health Regulation
No. 24 of 2022. There is a need to increase awareness and provide training for
healthcare providers on the importance of complete and timely EMR
documentation.