Overview of the Completeness of Inpatient Medical Record Files at Bintang General Hospital

Abstract

Hospitals are required to organize medical records that aim to create orderly administration. Completeness of filling in inpatient medical record files completely and on time can be a support in improving the quality of health services. The purpose of this study was to determine the completeness of inpatient medical record files at Bintang General Hospital. The type of research used is quantitative descriptive research. The sampling technique used simple random sampling with a total of 277 inpatient medical record files. The instrument used was a checklist. Data analysis used was univariate analysis. The results of the study obtained include the percentage of completeness of identification components at Bintang General Hospital, namely with a complete category of 277 (100%) and incomplete as many as 0 (0%), complete authentication components as many as 209 (75.5%) and incomplete as many as 68 (24.5%), complete important recording components as many as 203 (73.3%) and incomplete as many as 74 (27.7%), complete correct documentation components as many as 256 (92.4%) and incomplete as many as 21 (7.6%). Based on the results of the research that has been conducted on the completeness of inpatient medical record files at Bintang General Hospital, it can be concluded that there are still incomplete inpatient medical record files. The suggestion from this research is that the management and medical record officers of the hospital can improve socialization related to filling in the completeness of medical record files which can later increase the awareness and discipline of nurses and doctors concerned in completing medical record files through good cooperation.

Keywords: Completeness, Inpatient Medical Records, Quality