Analisis Faktor Penyebab Ketidakpatuhan Pengisian RME Rawat Jalan di Puskesmas Rambipuji

Gusti, Andini Fi Ramadhani Ciptaning (2026) Analisis Faktor Penyebab Ketidakpatuhan Pengisian RME Rawat Jalan di Puskesmas Rambipuji. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Non-compliance with outpatient EMR completion remains a problem in healthcare services, including at Rambipuji Community Health Center. This problem is indicated by incomplete EMR documentation, with the completion rate during October to December 2025 failing to reach 100%. This study aimed to analyze the factors contributing to non-compliance with outpatient EMR completion at Rambipuji Community Health Center based on behavioral theory. A qualitative method was employed, with data collected through interviews, observations, documentation, and brainstorming. The research informants consisted of one physician, one midwife, one dental nurse, one community health center head, one medical record officer, and one SIK officer. Data were analyzed based on predisposing, enabling, and reinforcing factors. The results showed that the main factor contributing to non-compliance was an enabling factor, namely the EMR application did not provide an asterisk (*) as an indicator of mandatory fields that must be completed. This condition made it difficult for healthcare workers to clearly identify which items were required and potentially contributed to incomplete EMR documentation. Other contributing factors included insufficient knowledge among healthcare workers regarding mandatory EMR components and inadequate supporting facilities and infrastructure, particularly computers and internet networks that did not fully meet users’ needs. Recommended improvements include adding asterisks to all mandatory fields in the EMR application, improving healthcare workers’ knowledge through training and socialization, and gradually improving facilities and infrastructure. Improving EMR application should be prioritized and supported by strengthening healthcare workers’ competencies and fulfilling facility and infrastructure needs to improve compliance with outpatient EMR completion.

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