Design of a Web-Based Medical Record Correspondence Information System with an Audit Trail Feature at Dustira Level II Hospital

Abstract

Medical record correspondence management at Dustira Level II Hospital is still carried out through processes that are not yet optimal, particularly in recording user activities, so monitoring, tracking data changes, and supervising medical record document management have not been effective. This study aimed to design a web-based Medical Record Correspondence Information System equipped with an Audit Trail feature to support more structured, secure, and accountable management of medical record correspondence. A descriptive qualitative approach was used, with data collected through observation, interviews, and documentation studies. System development employed the Waterfall method, consisting of requirements analysis, system design, program coding, testing, and maintenance. The system was developed using PHP and MySQL and designed using a flowmap, context diagram, Data Flow Diagram Level 1, and Entity Relationship Diagram. The resulting application manages patient data, physicians, users, medical resumes, discharge summaries, death claims, file-loan registers, reports, and user activity logs. Black Box Testing showed that all tested functions were valid. The Audit Trail constitutes the key feature by automatically documenting user activities to strengthen security, monitoring, transparency, and accountability.