International Journal of Computer and Information System (IJCIS) Peer Reviewed Ae International Journal Vol : Vol.
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August 2025 e-ISSN : 2745-9659 https://ijcis.
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php/ijcis/index Analysis Of The Design Of The Inpatient Medical Record Completeness Audit Application At Prof.
Dr.
Margono Soekarjo Purwokerto Regional Hospital 1st Elisabeth Yuga Nova Meganingtyas.
Sri Wulandari2 Politeknik Indonusa Surakarta.
Solo.
Indonesia elisabethyuga11@gmail.
com1, sriwulandari@poltekindonusa.
AbstractAi The completeness of inpatient medical records plays a vital role in ensuring the quality of healthcare services and compliance with hospital accreditation standards.
This study aims to design an inpatient medical record audit application that addresses existing inefficiencies in manual audit processes at RSUD Prof.
Dr.
Margono Soekarjo Purwokerto.
The research was conducted using the System Development Life Cycle (SDLC) with a waterfall model approach, consisting of needs analysis, system design, coding, and testing.
Data collection involved observation and interviews with inpatient coding staff, which revealed several issues in the current Google Spreadsheet-based audit system, including inflexible checklists, high risk of data loss, poor synchronization, and duplicate entries.
The proposed web-based application offers functional features such as multi-user login, patient data upload, dynamic checklists, open and close audit forms, and graphical audit reports.
Non-functional requirements emphasize security, accessibility, simplicity, and responsiveness.
User requirements focus on ease of navigation, printable reports, and support for daily work routines.
The system was implemented using JavaScript and tested through black-box testing, which confirmed all functionalities performed as expected.
User satisfaction was evaluated through a questionnaire distributed in the medical records department with 13 respondents, 1 department head and 12 coders, the results showed an overall satisfaction level of 92.
This application improves audit efficiency, reduces input errors, and supports hospital efforts to meet accreditation indicators.
The findings suggest that a well-designed information system can significantly enhance the management and monitoring of medical record completeness.
Keywords: Medical record audit, hospital information system.
SDLC
INTRODUCTION
In an era of globalization driven by rapid advancements in information technology, the healthcare sector is under increasing pressure to improve the quality of medical services.
Information technology has become an essential component of modern healthcare systems streamlining administrative processes, enhancing diagnostic precision, increasing service efficiency, and optimizing patient care.
As public expectations for high-quality healthcare continue to rise, the integration of technology into healthcare delivery is no longer optional but a necessity .
A key aspect of delivering quality care lies in the effective management of medical data ensuring that it is accurate, well-organized, and easily accessible to medical personnel.
This depends heavily on comprehensive and detailed documentation within patientsAo medical records.
Medical record audits serve as a critical tool for evaluating the completeness and quality of clinical documentation, while also ensuring compliance with health service standards and legal regulations Journal IJCIS homepage - https://ijcis.
net/index.
php/ijcis/index .
Currently, traditional audit methodsAi typically conducted manually by reviewing physical filesAiare time-consuming, error-prone, and inefficient, especially when managing large volumes of records.
To address these limitations, healthcare institutions are beginning to adopt system-based audits integrated with electronic medical records (EMR.
, which allow for faster, more accurate, and more efficient processes .
In parallel with these advancements, numerous applications have been developed to improve the efficiency of medical record audits.
These tools aim to boost both the accuracy and speed of audits by automating the review process.
Network-based systems for quantitative analysis have proven effective in meeting user expectations and resolving workflow challenges.
They are capable of evaluating the completeness of medical records and tracking healthcare providers' documentation However, despite these improvements, many hospitals still struggle to implement these Common obstacles include a mismatch between system capabilities and user Page 262 International Journal of Computer and Information System (IJCIS) Peer Reviewed Ae International Journal Vol : Vol.
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php/ijcis/index needs, along with difficulties integrating audit tools into existing hospital information systems .
An initial study conducted at Prof.
Dr.
Margono Soekarjo Purwokerto Regional General Hospital found that, although a medical record audit application had been incorporated into the hospitalAos system, inconsistencies were identified for example, differences between the documented and actual number of patients in each room.
During the use of the application from September 2024 until now, it still has several shortcomings, including .
the checklist in the medical record audit system is defaulted, .
if a human error occurs where the officer accidentally deletes a certain item, it will affect all sections, .
the way patients enter and exit are often not the same, .
the form that must be filled in is confusing, and several system errors have occurred which cause delays in conducting medical record audits, .
efficiency in filling out inpatient medical record completeness audits, .
often occurs 2 times storage in 1 patient.
This makes the medical record audit system less The information design system for the completeness of medical record files has managerial implications for hospitals, namely an information system that helps in managing, storing, and displaying data accurately.
Ensuring information is processed using appropriate software and presented in an easy-to-understand manner .
Conducting effective medical record audits is essential for hospital operations, particularly in meeting accreditation standards.
Accreditation organizations assess the quality of healthcare services based on the accuracy and completeness of medical records.
One key indicator is the percentage of documentation completed within 24 hours after a patientAos discharge, with the ideal target being 100%.
This standard holds particular significance for Prof.
Dr.
Margono Soekarjo Purwokerto Regional General Hospital, which holds a Type A designation, making quality improvement a central focus.
This study plays an important role in supporting the hospitalAos efforts to establish a more efficient, precise, and responsive audit system.
Unlike earlier research, this study emphasizes three main aspects: the audit process for evaluating inpatient record completeness, user needs for the information Journal IJCIS homepage - https://ijcis.
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php/ijcis/index system, and the development of the audit Incomplete electronic medical records continue to present challenges, particularly because they often serve as the sole documentation of a patientAos clinical course during hospitalization.
Successful EMR implementation requires thorough and continuous documentation review to ensure data integrity and clinical accountability .
II.
RESEARCH METHODS
The software development method employed in this research is the Waterfall model, which is one of the most established and widely used approaches in system development.
As one of the earliest structured models in software engineering, the Waterfall model adopts a systematic and sequential process, where each development phase must be completed before progressing to the next.
This linear progression allows for effective quality control and thorough monitoring at every stage.
When applied to Information Systems (IS) development, the Waterfall model offers the advantage of structured documentation and clear milestone tracking, thereby enhancing the system's ability to meet user requirements effectively .
The diagram of the waterfall model is as follows:
Figure 1.
Waterfall Model The Waterfall model utilizes a systematic and sequential approach to software development .
The development process in this study began with the analysis phase, which involved direct observation and interviews with coders at Prof.
Dr.
Margono Soekarjo Purwokerto Regional General Hospital.
This was conducted to gain a comprehensive understanding of the system requirements and the workflow for auditing the completeness of inpatient medical records.
In the design phase, the gathered requirements were further analyzed and translated into visual representations, including Use Case Diagrams.
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php/ijcis/index Class Diagrams, and interface mockups.
These tools served to define the system's structure and user interactions more clearly.
The next stage, coding, involved implementing the design using Visual Studio Code and the JavaScript The application was developed as a web-based system, characterized by interconnected web pages and supported by a domain (URL) and hosting services to store and manage data .
Once development was complete, the system underwent the testing phase using the black-box testing method to ensure that all functionalities operated according to design i.
Design After knowing the needs of the medical record file completeness audit system based on the form currently used to design the system to be developed, the following is a description of the system design flow through a DFD chart is use to illustrated with a number of specific symbols to show the data movement that occurs within a business system .
and describe the system as a network of functional processes connected to each other by data flow and , both manually and RESULT AND ANALYSIS The application design in this study uses the Waterfall System Development Life Cycle (SDLC) model approach, which consists of the stages of Analysis.
Design, implementation (Cod.
, and Test.
Analysis The needs analysis for designing the inpatient medical record completeness audit application encompasses three main aspects: functional needs, non-functional needs, and user needs.
From a Figure 2.
DFD Audit System functional perspective, the system must offer userBased on the Data Flow Diagram (DFD) in friendly audit features, implement separate login systems for coders and auditors, allow data input Figure 2, the medical record audit system begins via checklists that are not automatically filled, and with the auditor logging in as the primary user.
After logging in, the auditor uploads data related to generate recapitulation reports.
patients, rooms, and cases.
Next, the auditor performs the audit process These reports should cover key indicators such as completeness, readability, and the using two main features: Open Audit and Close timeliness of medical record documentation.
In Audit.
The Open Audit feature is used to verify the terms of non-functional requirements, the system completeness of newly entered patient data, while is designed with a focus on data security through the Close Audit feature is used to finalize audits for authentication mechanisms, improved audit patients who have been discharged.
Both features process efficiency, and overall ease of use .
The are integrated with the data processing component, user needs highlight the importance of an intuitive which generates a report covering key aspects such interface, mechanisms to prevent duplicate entries, as completeness, readability, and timeliness of and the ability to distinguish between audited and medical record documentation.
This report is then made accessible to the Head of unaudited data.
Medical Records and the Hospital Director for the The system is developed as a web-based purpose of evaluating service quality.
The system application using the JavaScript programming is designed to facilitate a structured and transparent It is accessible through internet browsers audit process in accordance with applicable such as Google Chrome.
Mozilla Firefox, and hospital accreditation standards.
Journal IJCIS homepage - https://ijcis.
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php/ijcis/index Furthermore, the flow illustrated in Figure 2 is Regional General Hospital .
The results of the elaborated through a Use Case Diagram, which application design before implementation are as visualizes the interactions between different user follows:
roles and the system.
A Use Case Diagram, as defined in Unified Modeling Language (UML), is a tool used to represent the functional relationships .
Figure 4.
ApplicationAos Dashboard Figure 4 shows an example of a dashboard design prototype for a web-based medical records audit application.
This prototype, or mockup, served as the basis for creating the original design Figure 3.
Auditor Usecase for the medical records audit application.
The The process begins with a login stage, where medical records audit application includes 10 the auditor must authenticate to gain access to the prototype design forms: Login Page.
Dashboard.
Upon successful login, the auditor is Upload Page.
Open Audit Page.
Open Audit Form, directed to the Dashboard Menu, which serves as Close Audit Page.
Input Audit Page.
Report Page, the central navigation hub of the application.
User Page, and User Type Page.
From the dashboard, the auditor can access several key features, including the Upload File, c.
Code Open Audit Record.
Close Audit, and Report After the Design System design phase is To initiate the audit process, the auditor complete, the next step is to implement the design must first upload documents related to the patient's into program code.
This process is a crucial step in medical record.
This step is followed by data input, information system development, where all which involves entering essential information such interface components and system logic flows as the patient's identity, treatment room, and the developed during the design phase are translated medical case to be audited.
into a executable application.
Once the data is entered, the auditor can The implementation process involves coding proceed with the Open Audit function.
This feature the website pages, setting up the database, and is used to open an audit session for medical records initial testing to ensure everything is working uploaded the previous day, as audits are conducted properly .
the day after data entry.
In contrast, the Close In this case, the previously designed prototype Audit function is used for patients discharged on serves as a reference in the coding process, the current day.
including page structure, button functions, data validation, and the information storage and By following this structured process, the processing mechanisms that occur on the system's system enables auditors to conduct medical record backend.
An example of this coding is shown in audits more efficiently and accurately.
It also Figure 5 below.
supports the generation of informative reports, which play a critical role in evaluating the quality of medical records at Prof.
Dr.
Margono Soekarjo Journal IJCIS homepage - https://ijcis.
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php/ijcis/index Tested Features Open Audit Ae Filter data Open Audit - Form Figure 5.
Code Test The testing phase is carried out to verify the functionality of the completed system and ensure that the written program code works according to the user's design expectations.
This process is important to try and find out whether the system that has been designed is running properly according to plan.
Testing is conducted using blackbox testing techniques.
Black box testing is a testing method carried out on software by observing the execution results through test data and checking the functionality of the software So, black box testing focuses on evaluating the external appearance .
, such as input and output.
The following are the results of the blackbox testing conducted by the author.
Table 1.
Blackbox Testing Tested Features Login Page Login Page Dashboard Page Upload CSV File Upload CSV File Open Audit Form Test Scenarios Users Users Displays audit data Input Uploadin g files in Upload File CSV View the audit list Fill in the User and Password that have not been Fill in the User and Password that have been set Expected Output Login failed Close Audit Master Data Ae User Side Bar Navigation Patient Audit Chart Result Passed Save Audit Form Login Successfully Passed Open Audit.
Close Audit data, activity Passed File jpg` / Upload Failed Passed Upload Success Displays patient data Passed Audit Close Audit Passed Journal IJCIS homepage - https://ijcis.
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php/ijcis/index Audit Form Empty Validation Test Scenarios Upload Filter by n date Select the Input Expected Output according to table format The table only displays data that matches the Result Data is saved when you click "Save" Passed Show list Discharg Patient Audits Data with `CLOSE_AU DIT` appears Passed Access the user type page Access the user type page A list of User Passed Access the User ent page Click on (Dashboa rd.
Open Audit.
Select the .
ropdow Partially fill out the form then click "Save" Blank form then "Save" User types Passed Click Menu The page according to the menu Passed The graph according to the selected Passed Check Form Passed Do not fill in any A warning appears or is Passed "CHAD MINAH" / "D231" "13/02/20 Click a Passed From the results of the tests carried out, all scenarios created to test the system all produced results as expected, namely all features ran well and according to the expected functions.
Analysis After the application design process using the Waterfall model System Development Life Cycle (SDLC) approach, which consists of the stages of (Analysi.
, (Desig.
, implementation (Cod.
, and system testing (Testin.
has been fulfilled, the website-based Page 266 International Journal of Computer and Information System (IJCIS) Peer Reviewed Ae International Journal Vol : Vol.
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php/ijcis/index inpatient medical record completeness audit application was successfully built with the following details:
Statement This system is easy to even if you are new to I can use the features in the Score Precentage The and guide to using the system are very clear and easy to I am with the and ease of within the The system helps speed up the process of The features in the support my work needs.
Figure 5.
Dashboard Application Figure 5 shows that the application has been created in accordance with the prototype or mockup design from the previous stage.
The features are detailed as follows:
On the left side of the screen, there is a vertical navigation menu containing several key features:
Dashboard.
File Upload.
Open Audit.
Close Audit.
Reports, and the Master Data menu, which consists of Users and User Types.
This navigation menu provides easy user access to various important system functions.
Above the main area, there are four information boxes presenting summary data: the number of Open Audits.
Close Audits.
Completed Open Audits, and Completed Close Audits, each with a value or data value processed in the system.
This information presentation aims to provide a quick overview of the status and progress of ongoing Below is a bar chart showing the medical record file report for the current month.
The results of the assessment of user understanding and satisfaction with the system were assessed by administering a questionnaire to 13 auditors.
The results are as follows:
Table 2.
User Understanding and Satisfaction Questionnaire No Statement Score Precentage I understand the purpose d medical record audit Journal IJCIS homepage - https://ijcis.
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php/ijcis/index In terms of efficiency, the application reduces the auditorsAo workload through several key First, data uploads are now performed only once during patient admission .
pen audi.
, as the system automatically carries the data forward Overall.
I for the close audit stage.
Second, checklist marks are retained even when the patient data is am satisfied reopened, preventing duplicate entries.
Third, with the forms filled out during the open audit phase automatically appear during the close audit, ion of this eliminating the need for re-entry.
Overall, the use of this application saves time in data uploads, record audit reduces the risk of duplicate input, accelerates form completion, and generates automated reports.
The test of user understanding and satisfaction The average time required for open audit entry was with the implementation of the Medical Record reduced from 1 minute 10 seconds to 1 minute 6 Audit Application at Prof.
Dr.
Margono Soekarjo seconds, and for close audit from 2 minutes 30 Regional General Hospital was measured using a seconds to 1 minute 36 seconds.
These results linkert scale, with a scale of 1 = Strongly Disagree demonstrate that the web-based application 2 = Disagree 3 = Neutral 4 = Agree 5 = Strongly significantly improves auditor performance while Agree.
Based on the results obtained, the average minimizing data duplication and delays in the audit score was 4.
63 with a percentage of 92.
59% of process.
respondents being satisfied and understanding the VI.
CONCLUSION
Web-based Medical Record Audit Application.
The implementation of a web-based audit A web-based inpatient medical record audit application system has proven to enhance the application has been successfully developed and effectiveness and efficiency of the medical record implemented at Prof.
Dr.
Margono Soekarjo documentation audit process.
This system Regional General Hospital using the Waterfall simplifies the monitoring of document completion, model, and has been adapted to align with the as auditors can assess each form based on specific workflow of medical coders.
The application is parameters such as patient identity, legibility, equipped with features that enhance audit authentication, and audit timing.
The dashboardAos efficiency, has passed black-box testing, and graphical features also enable both auditors and received positive responses from users for its ease management to observe monthly trends in of use and relevant functionalities.
This system documentation completeness, allowing for quicker enables accurate and automated monitoring of corrective actions.
Moreover, this application medical record completeness.
Based on the supports the hospital accreditation standards questionnaire results, the application achieved an concerning the completion of medical records auditor satisfaction level of 92.
59%, with an within 2x24 hours.
average score of 4.
These findings indicate that Trial results involving 13 respondents showed the application functions effectively and is suitable consistent completeness scores, as all data for implementation at Prof.
Dr.
Margono Soekarjo originated from the same source.
A significant Regional General Hospital, supporting efforts to difference emerged in the duplication of data meet medical record quality indicators in entries: in the Google Spreadsheet system, accordance repeated data often occurred due to input errors and Accreditation bodies evaluate the quality of multiple saves.
In contrast, the web-based healthcare services based on the accuracy and application is programmed to retain only the latest completeness of medical documentation.
One saved entry, ensuring that the number of audited critical indicator is the percentage of patients aligns with the actual number of documentation completed within 24 hours after inpatients, thereby improving data accuracy.
patient discharge, with an ideal target of 100%.
Statement New and style look Score Precentage Journal IJCIS homepage - https://ijcis.
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php/ijcis/index REFERENCES