Completeness of Informed Consent Medical Record Form Electronics (RME) In Hospitalized Patients

Abstract

A hospital is a health service institution that provides complete individual health services in 
the form of inpatient, outpatient and emergency services. In its implementation, documents are 
needed, namely medical records which contain notes or documents explaining the patient's identity, 
examination, treatment, actions and other services provided to the patient.   However, in practice, 
there are still many components of the medical record that are not completely filled in by health 
workers due to various factors, so that there are often gaps in the medical record form which should 
be filled in with patient data. This study aims to determine the completeness of filling out informed 
consent for electronic medical records for inpatients at Klungkung Regional Hospital. This research 
is quantitative research that uses a correlative analytical design. The number of samples in this study 
was 81 items. Based on the research results, it can be concluded that regarding the completeness of 
filling in the characteristics of the 81 samples was complete with 100% rate. Regarding the 
completeness of filling out the identity of the informed consent form from 81 samples, incompleteness 
was still found in the filling, where the complete percentage was 12.3% while the incomplete 
percentage was 87.7%. Regarding the completeness of important reports on the informed consent 
form from 81 samples, incompleteness was still found in the filling, where the complete percentage 
was only 8.6% while the incomplete percentage was 91.4%. Regarding the completeness of filling out 
the authenticated informed consent form from 81 samples, incompleteness was still found in the 
filling, where the complete percentage was only 9.8% while the incomplete percentage was 90.2%. It 
is hoped that incomplete data will be checked and filled in again when the patient receives inpatient 
services