Physician Adherence to Common Cold Clinical Practice Guidelines: an Electronic Medical Record Audit Using SIMKES Khanza
Abstract
Common cold (ICD-10 J00) is a self-limiting viral infection; however, inappropriate antibiotic prescribing remains a global concern. Electronic Medical Records (EMR) can facilitate clinical audits, but evidence from Indonesian primary care settings remains limited. This study aimed to assess physician adherence to Clinical Practice Guidelines (CPG) for common cold using SIMKES Khanza EMR at Sehati Kudus Primary Clinic. A retrospective clinical audit was conducted on 753 EMR records from July to December 2025 using a 32-item CPG-based checklist. Data were analyzed descriptively using SPSS version 26. The results showed that overall physician adherence to common cold Clinical Practice Guidelines (CPGs) was 59.9%, with a mean adherence score of 19.19 out of 32 assessment items, categorized as sufficient. The highest adherence was observed in EMR documentation completeness (80.8%) and diagnosis (65.0%), whereas adherence was lower in anamnesis (55.5%), physical examination (52.7%), and management (45.5%). The management component, which included non-pharmacological therapy, symptomatic treatment, and rational antibiotic use, demonstrated the lowest adherence, highlighting important gaps in evidence-based management practices despite good documentation quality. Physician adherence to common cold CPG was suboptimal, particularly in management-related practices. Although SIMKES Khanza facilitated structured clinical documentation and supported EMR-based clinical audits, improvements in clinical assessment, patient education, and adherence to evidence-based management recommendations are needed. Regular clinical audits and quality improvement initiatives may help strengthen guideline implementation in primary care settings.
Keywords: Common Cold, Guidelines Adherence, Electronic Medical Records, Primary Health Care
Full Text:
PDFReferences
Arini, Merita, Listiowati, E., Pratama, D. D., Pramayanti, Y., & Samsudin, M. A. (2025). Understanding user acceptance of electronic medical records: A mixed method study. Media Publikasi Promosi Kesehatan Indonesia, 8(9), 876–898. https://doi.org/10.56338/mppki.v8i9.7581
Asmirajanti, M., Aliyupiudin, Y., Rusmini, S., Rumondang, P. R., Chanafie, D., & Supyono, S. (2021). Penerapan standar akreditasi terhadap mutu dan keselamatan pasien sebelum dan selama pandemi Covid-19. The Journal of Hospital Accreditation, 3(2), 65–70. https://doi.org/10.35727/jha.v3i2.93
Choirunnah, L., Budi, S. C., & Intanida, W. R. (2022). Readiness to implement electronic medical records based on the California community clinic EHR assessment and readiness (CCCEAR) instrument. Jurnal Aisyah: Jurnal Ilmu Kesehatan, 7(4), 1363–1370. https://doi.org/10.30604/jika.v7i4.1921
Creswell, J. W., & Plano Clark, V. L. (2018). Designing and conducting mixed methods research (3rd ed.). SAGE Publications.
Fauzil, F., Yusuf, Y., & Astiena, A. K. (2022). Analisis kepatuhan DPJP dalam kelengkapan pengisian rekam medis dan faktor-faktor yang mempengaruhinya di RSUD dr. Rasidin Padang. Human Care Journal, 7(2), 359–366. https://doi.org/10.32883/hcj.v7i2.1665
Habsari, B. V., & Wulan, I. G. A. K. (2022). Analisis kesesuaian terapi skabies terhadap panduan praktik klinis (PPK) di Puskesmas Songgon, Banyuwangi. Jurnal Ilmiah Medicamento, 5(3), 248–253.
Handayani, E., & Hariyati, T. S. (2024). Nurses’ perception on the implementation of nursing care documentation using electronic medical record: A literature review. Jurnal Ilmiah Ilmu Keperawatan Indonesia, 13(4), 138–151. https://doi.org/10.33221/jiiki.v13i04.3046
Haryadi, J. A., Setiawan, A., & Maengkom, M. R. (2024). Studi literatur terhadap peran dan manfaat audit operasional terhadap efektivitas pelayanan kesehatan di rumah sakit. EKOMA: Jurnal Ekonomi, Manajemen, Akuntansi, 4(1), 553–563.
Kasse, G. E., Cosh, S. M., Humphries, J., & Islam, M. S. (2025). Pattern and appropriateness of antimicrobial prescription for acute respiratory tract infection in primary healthcare settings in Ethiopia. Antimicrobial Resistance and Infection Control, 14(1), Article 23. https://doi.org/10.1186/s13756-025-01612-8
Kementerian Kesehatan Republik Indonesia. 2022. Keputusan Menteri Kesehatan Republik Indonesia Nomor HK.01.07/MENKES/1186/2022 tentang Panduan Praktik Klinis bagi Dokter di Fasilitas Pelayanan Kesehatan Tingkat Pertama. Jakarta: Kementerian Kesehatan Republik Indonesia
Liu, X. L., Wang, T., Tan, J. Y., Stewart, S., Chan, R. J., Eliseeva, S., Polotan, M. J., & Zhao, I. (2022). Sustainability of healthcare professionals’ adherence to clinical practice guidelines in primary care. BMC Primary Care, 23(1), Article 198. https://doi.org/10.1186/s12875-022-01641-x
Mutia, D. S., & Dhamanti, I. (2023). Patient safety culture measurement in primary health care: Literature review. Jurnal Kesehatan Komunitas, 9(2), 418–430.
Mutmainah, Kusmita, L., Franyoto, Y. D., & Puspitaningrum, I. (2022). Penyuluhan penggunaan antibiotik yang bijak dan rasional pada PKK di Desa Bejalen Ambarawa. Jurnal DiMas, 4(2), 39–42. https://doi.org/10.53359/dimas.v4i2.40
Nurfitria, B., Rania, F., & Rahmadiani, N. W. (2024). Implementasi rekam medis elektronik di institusi pelayanan kesehatan di Indonesia. Jurnal Insan Cendekia, 11(1), 80–91.
Patandung, R., Ishariyanto, R., & Enjelina, S. M. (2024). Edukasi mengenai penggunaan antibiotik yang rasional kepada pengunjung Apotek Java Farma di Kelurahan Telukan, Kecamatan Grogol, Sukoharjo. Jurnal Pengabdian Masyarakat, 1(10), 360–366.
Pereira, V. C., Silva, S. N., Carvalho, V. K. S., Zanghelini, F., & Barreto, J. O. M. (2022). Strategies for the implementation of clinical practice guidelines in public health: An overview of systematic reviews. Health Research Policy and Systems, 20(1), Article 45. https://doi.org/10.1186/s12961-022-00815-4
Pietrzykowska, M., Nowicka-Sauer, K., & Siebert, J. (2021). Respiratory tract infections in primary health care: Prevalence and antibiotic prescribing in a primary care practice during one year. Family Medicine and Primary Care Review, 23(2), 203–208. https://doi.org/10.5114/fmpcr.2021.105924
Pratama, I. F., & Purwanto, E. (2023). Sistem informasi manajemen rumah sakit dalam meningkatkan efisiensi. COMSERVA: Jurnal Penelitian dan Pengabdian Masyarakat, 3(7), 2571–2576. https://doi.org/10.59141/comserva.v3i07.1044
Putra, B. R., Rosyidah, & Hariyono, W. (2024). Analisis penerapan rekam medis elektronik pada Klinik Utama Bunafsi di Kabupaten Wonogiri. Jurnal Kesehatan, 32(3), 167–186.
Sada, D. A., Husain, Y. I., & Misbah, Z. A. (2023). Assessing adherence to clinical practice guidelines among primary care physicians in Bahrain: A cross-sectional study. Oman Medical Journal, 38(4), Article e523. https://doi.org/10.5001/omj.2023.84
Sari, D. Y., Kismoyo, C. P., Paninsari, D., Sitepu, A. B., Marsilia, I. D., Yulianti, I., Mubayyina, F., Prabandari, F., Octavia, R., & Insani, S. D. (2025). Buku ajar persalinan. Optimal Untuk Negeri. https://books.google.co.id/books?id=PM6cEQAAQBAJ
Trina, D., & Sari, P. (2024). Pengaruh beban kerja terhadap kualitas dokumentasi keperawatan di instalasi rawat inap. Jurnal Keperawatan, 9(10), 1001–1010.
Yigzaw, K. Y., Chomutare, T., Wynn, R., Berntsen, G. K. R., & Bellika, J. G. (2022). A privacy-preserving audit and feedback system for the antibiotic prescribing of general practitioners: Survey study. JMIR Formative Research, 6(7), Article e31650. https://doi.org/10.2196/31650
Yossiant, S., & Hosizah, H. (2023). Implementasi rekam medis elektronik di Klinik Kidz Dental Care. Indonesian of Health Information Management Journal, 11(1), 50–55. https://doi.org/10.47007/inohim.v11i1.476
Zaadoud, B., & Chbab, Y. (2021). The performance measurement frameworks in health care: Appropriateness criteria for measuring and evaluating the quality-of-care performance through a systematic review. Management Issues in Healthcare System, 7, 11–34. https://doi.org/10.33844/mihs.2021.60603
Zhang, J., Symons, J., Agapow, P., Teo, J. T., Paxton, C. A., Abdi, J., Mattie, H., Davie, C., Torres, A. Z., Folarin, A., Sood, H., Celi, L. A., Halamka, J., Eapen, S., & Budhdeo, S. (2022). Best practices in the real-world data life cycle. PLOS Digital Health, 1(1), Article e0000003. https://doi.org/10.1371/journal.pdig.0000003
DOI: http://dx.doi.org/10.30829/contagion.v8i3.29558
Refbacks
- There are currently no refbacks.
Copyright (c) 2026 Hariyanto Ngadiman
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
