Kualitas Data Rekam Medis Elektronik di RSJD dr. Arif Zainudin Surakarta

Nandani Kusuma Ningtyas, dr. M. Lutfan Lazuardi, M.Kes., Ph.D.

2025 | Tesis | MAGISTER KEBIJAKAN DAN MANAJEMEN KESEHATAN

Latar belakang: Skizofrenia merupakan salah satu penyumbang utama beban penyakit dan disabilitas global, dengan individu yang terkena dampak menghadapi tingkat penyakit kronis lebih tinggi, peningkatan angka kematian, dan penurunan harapan hidup. Di Indonesia, layanan kesehatan jiwa diberikan sepanjang rentang hidup, menargetkan orang berisiko, orang dengan gangguan jiwa, dan masyarakat. Namun, masih ada tantangan dalam mengelola data kesehatan jiwa, terutama pengumpulan data, pelaporan, dan integrasi pengetahuan. Data yang lengkap dan konsisten penting dalam manajemen skizofrenia yang efektif, karena memengaruhi diagnosis, perencanaan pengobatan, dan kesinambungan perawatan.

Tujuan: Mengidentifikasi kualitas data rekam medis elektronik kasus skizofrenia di RSJD dr. Arif Zainudin Surakarta.

Metode: Jenis penelitian mixed method melalui desain sequential explanatory. Pengumpulan data kuantitatif melalui observasi rekam medis elektronik kasus skizofrenia pada unsur kelengkapan dan konsistensi. Pengumpulan data kualitatif melalui in-depth interview. Analisis data kuantitatif menggunakan analisis statistik deskriptif. Analisis data kualitatif menggunakan analisis tematik.

Hasil: Kelengkapan data RME kasus skizofrenia adalah 100%. Konsistensi tercatat sebesar 79,9% untuk diagnosis, 98,7% untuk pemberian obat, dan 88,6% untuk penggantian atau penghentian obat. Faktor-faktor terkait manusia yang memengaruhi kualitas data RME dikelompokkan dalam tema komitmen dan ketelitian. Faktor-faktor teknologi terdiri dari kecepatan akses, keamanan, kemempuan perangkat, persepsi pengguna, dan evaluasi. 

Kesimpulan: Peningkatan komitmen dan ketelitian pengguna dapat dilakukan melalui penilaian terstruktur, penggunaan instrumen standar, dan kepatuhan terhadap Prosedur Operasional Standar (SOP). Selain itu, pemantauan rutin, verifikasi data, dan penyelarasan alur kerja EMR dengan proses klinis sangat penting. Keterbatasan infrastruktur teknologi dapat diatasi melalui pengarahan kebijakan untuk mencari dukungan dan minat pemerintah dalam perolehan donor pihak swasta.

Background: Schizophrenia is a major contributor to global disease burden and disability, with affected individuals facing higher rates of chronic illness, increased mortality, and reduced life expectancy. In Indonesia, mental health services are delivered across the life span, targeting at-risk individuals, those with mental disorders, and the population. However, challenges persist in managing mental health data, especially in data collection, reporting, and knowledge integration. Completeness and consistency data is critical for effective schizophrenia management, as it influences diagnosis, treatment planning, and care continuity.

Objective: To evaluate the quality of electronic medical record (EMR) data for schizophrenia cases at RSJD dr. Arif Zainudin Surakarta.

Method: A mixed-methods approach with a sequential explanatory design was employed. Quantitative data were gathered through observation of EMR documentation, focusing on completeness and consistency. Qualitative data were collected through in-depth interviews. Descriptive statistics were used for quantitative analysis, and thematic analysis was applied to qualitative data.

Results: EMR data completeness for schizophrenia cases reached 100%. Consistency was 79.9% for diagnosis, 98.7% for drug administration, and 88.6% for medication changes or discontinuation. Human factors influencing data quality were categorized into commitment and thoroughness. Technological factors included access speed, system security, device capability, user perception, and system evaluation.

Conclusion: Enhancing EMR data quality requires strengthening user commitment through structured evaluations, standardized tools, and adherence to SOPs. Additionally, routine monitoring, data verification, and alignment of EMR workflows with clinical processes are crucial. Technological infrastructure challenges should be addressed through supportive policies and engagement with both governmental and private stakeholders.

Kata Kunci : kelengkapan data, konsistensi data, kualitas data, rekam medis elektronik, skizofrenia, data completeness, data consistency, data quality, electronic medical record, schizophrenia