The completeness of medical record file in December 2018, January 2019 and February 2019 is not complete, so it does not Fulfill the Minimum Standards of Hospital Services. The incomplete filling of medical record files will cause the records to be out of sync and the patient's previous health information difficult to identify. The purpose of the study was to identify the completeness of filling medical record files and the factors causing incompleteness of filling medical record files for inpatients at RSUP Dr. Kariadi Semarang. This research was a qualitative research. The research subjects consisted of 2 officers in charge of medical records. The object of the study was 86 samples of inpatient medical record files from 25-28 February 2019 based on the Slovin formula. The results of the research that the completeness of the patient's identity, the completeness of important reports, the completeness of inpatient medical record file authentication and the completeness of correct recording, indicated that the completeness of filling the medical record was quite high. The incompleteness of filling in the inpatient medical record file was caused by several factors, specifically the officer factor (man), procedural factor (method), tool factor (material), machine factor and motivation factor.

RSUPN Dr. Cipto Mangunkusumo is one of the hospitals whose services have used Electronic Health Record (EHR). The implementation of EHR is frequent loading and errors during service and lacking for several menus. The research purpose was to evaluate user satisfaction related to reporting on the Electronic Health Record (EHR) in the central medical records unit Dr. RSUPN. Cipto Mangunkusumo. This research was quantitative descriptive with population of all Electronic Health Record users in the central medical record unit, with 50 sample of respondents. The sampling technique was conducted by sistematic random sampling. Data was analyzed through scoring and presented in table form. The results showed that the dimension of accuracy was 73.28%, format was 71.6%, ease of use was 69.2%, content was 69.2 %, and timelines was 65.66%. These dimension scores indicated good criteria or the user was satisfied with the current Electronic Health Record (EHR) condition, but it requires the development of information systems by adding and adjusting modules contained in the EHR so that user satisfaction continues to increase. Keywords: evaluation; electronic health record (HER); end user computing satisfaction (EUCS) ABSTRAK Rumah Sakit Umum Pusat Nasional (RSUPN) Dr. Cipto Mangunkusumo merupakan salah satu rumah sakit yang pelayanannya sudah menggunakan SIMRS yang disebut Electronic Health Record (EHR). Penggunaan EHR sering loading dan error pada saat pelayanan dan ada beberapa menu yang masih kurang. Tujuan penelitian ini adalah untuk mengevaluasi kepuasan pengguna terkait pelaporan pada Electronic Health Record (EHR) di unit rekam medis pusat RSUPN Dr. Cipto Mangunkusumo. Penelitian ini adalah kuantitatif deskriptif dengan populasi seluruh pengguna Electronic Health Record di unit rekam medis pusat, dan sampel berjumlah 50 responden. Teknik pengambilan sampel dilakukan dengan sistematic random sampling. Analisa data dilakukan melalui skoring dan disajika ndalam bentuk tabel. Hasil penelitian menunjukkan bahwa dimensi keakuratan memiliki nilai tertinggi, yaitu 73,28%, tampilan 71,6%, kemudahan pengguna 69,2%, isi 69,2%, dan waktu 65,66%. Skor dalam dimensi tersebut termasuk dalam kriteria baik atau pengguna puas terhadap konsisi Electronic Health Record (EHR) saat ini, namun masih diperlukan pengembangan sistem informasi serta menambahkan dan menyesuaikan modul yang ada di dalam EHR sehingga kepuasan pengguna terus meningkat. Kata kunci: evaluasi; electronic health record (HER); end user computing satisfaction (EUCS)

Rumah Sakit X menerapkan pengelolaan rekam medis sebagai penunjang medis. Dokumen rekam medis belum terjaga keamanan dan kerahasiaannya, dimana banyak petugas medis lain keluar masuk ruang filing, terdapat petugas makan dan minum diruang filing, penyimpanan masih di rak terbuka, dan petugas atau mahasiswa penelitian membocorkan isi rekam medis pasien.  Tujuan dari penelitian ini adalah mengetahui determinan keamanan dan kerahasiaan dokumen rekam medis di Rumah Sakit X. Jenis penelitian yang digunakan dalam penelitian ini adalah penelitian kualitatif menggunakan metode brainstorming dengan teknik wawancara, observasi dan dokumentasi. Hasil yang didapatkan dalam penelitian ini adalah faktor karakteristik petugas terdiri dari tingkat pendidikan terakhir petugas SMA, umur petugas 32-38 tahun, dan jenis kelamin laki-laki. Faktor psikologi meliputi attitude seperti petugas masih makan dan minum, petugas medis lain keluar masuk, membuka dokumen rekam medis tanpa izin dan terdapat pembocoran isi dokumen rekam medis. Faktor motivasi meliputi petugas merasa puas dan kompetitif dalam bekerja. Faktor organisasi meliputi penghargaan berupa pujian dan kepemimpinan belum dilakukan pemberian petunjuk pergantian dokumen rekam medis yang hilang. Hasil brainstorming yang menjadi penyebab utama yaitu tingkat pendidikan petugas yang masih rendah yaitu SMA. Saran yang diberikan meliputi pendidikan lanjutan atau pelatihan, memberi evaluasi secara rutin dan piagam kepada petugas. Kata kunci : keamanan, kerahasiaan, penyimpanan

The filing room becomes one of the most supportive rooms in the service of patients' medical records as they are safely stored due to its confidentiality and legal aspects. Bhakti Husada General Hospital of PT. Rolas Nusantara Medika Krikilan Banyuwangi found 320 misfiling (no medical record documents were found) in March 2018. Misfiling inhibits doctor's services towards particular patients as no background information is provided in relation to patinets' previous diseases, thus it eventually affects the level of medical record continuity in hospitals. This study aims to analyze and determine prior causes of misfiling at Bhakti Husada General Hospital of PT. Rolas Nusantara Medika Krikilan Banyuwangi using USG (Urgency, Seriousness, Growth). The research uses qualitative approach and interviews, observation, documentation, questionnaires and brainstorming as data collection. The results indicated prior causes of misfiling beyond standard procedure. A wide range of efforts to solve this particular problem are needed including the socialization of tracer in the storage shelves and personnels assigned in the filing section.

Percentage of incompleteness of filling in the medical records of the Clinic Dr. M. Suherman shows thatthe Minimum Service Standards in the Hospital are not yet 100%. Incomplete data has shown that thecompleteness of filling medical record documents is still not in accordance with the specified standards.The incompleteness of filling out the medical record document may be caused by the performance factorof the officer in completing the inpatient medical record document. The purpose of this study is to analyzethe performance factors in filling out the record documents. The purpose of this study was to analyze theperformance factors in filling out medical records of inpatients at the Clinic dr. M. Suherman Jember. Thisstudy uses qualitative research that aims to identify and analyze performance factors in filling inpatientmedical record documents at the Clinic dr. M. Suherman Jember, who will be associated with performancetheory with personal factors, leadership factors, team factors, system factors, and situational factors, andusing the USG (Urgency, Seriousness, Growth) method to determine the main factors of the 5 factors thataffect performance as well as efforts to correct problems using brainstorming. The results of this studyobtained priority causes of the incompleteness of filling medical records documents for inpatients at theClinic dr. M. Suherman Jember is the lack of awareness of each individual related to filling medical recorddocuments, lack of evaluation and monitoring, lack of socialization, lack of understanding related to SOPfor filling medical record documents because there is no SOP for filling medical record documents, so theClinic, Dr. M. Suherman asked researchers to make SOPs for filling in the records of inpatients. As asuggestion, do a commitment to complete the completeness of filling medical record documents, conductsocialization, evaluation and routine monitoring, as well as making SOP for filling medical recorddocuments.