EVALUASI IMPLEMENTASI REKAM MEDIS DI INSTALASI RAWAT INAP RUMAH SAKIT PKU MUHAMMADIYAH YOGYAKARTA

Background: Medical Record has been implemented in Muhammadiyah Hospital since 2009. Although, its practice has faced several barriers mainly user resistance, complexity of technology contents, and knowledge of hospital human resources toward implementation of medical record. This study was to carried out evaluate the implementation of medical record according to HOT Fit framework by Yusof et al. (2008), the framework will be identified by technology, hospital human resources, and hospital organization of dimensions Objectives:,To identify the human resources characteristics that were used medical record, to identify benefit and barrier implementing medical record, and to evaluate implementation of medical record at inpatient department Muhammadiyah Hospital, Yogyakarta. Method: This research was a case study with mixed methods approaches. The subjects of this research were 2 physician/specialists, 5 nurses, 4 midwives, medical record manager, 3 medical record staff, 4 IT staff, and 1 quality assurance staff. Results: The results indicated that there were eight (38,10%) respondents stated that medical record system contents were not fitness with end user needs. There were ten (47,62%) respondents stated that hospital human resources lack of knowledge about components, functions, security system and knowledge about the paperless office. Seven (33,33%) respondents still resistance with system, and there were five (23,81%) respondents stated that job manner in hospital didn�t support enhancing performance in health information technology. Conclusion: All clinicians were not yet adopted the medical record in healthcare because user resistance toward medical record. Hence, we need a health policy and training step by step in order to enhancing health care at inpatient Muhammadiyah Hospital, Yogyakarta