Analysis of Completeness of Inpatient Discharge Summary Form in Electronic Medical Records

Abstract

The digital transformation in healthcare services demands efficiency, one of which is through the implementation of Electronic Medical Records (EMR). Filling out the Discharge Summary Form (DSF) is a crucial part of the medical record system to ensure continuity of care, documentation completeness, and data accuracy. This study aims to analyze the completeness of electronic DSF entries in the medical records of a private hospital in Denpasar. A descriptive quantitative method was used, with observation techniques applied to 284 inpatient documents collected during the period of November to December 2024. Univariate analysis was conducted by comparing the form contents to the completeness standards set by the hospital and the Ministry of Health, covering four aspects: patient identification, essential reports, authentication, and accurate data recording. A checklist was used as the research instrument. The results showed completeness levels of 100% for patient identification, 93.00% for essential reports, 100% for authentication, and 100% for data recording. The study recommends developing the EMR system with automatic reminders and warning indicators that enforce the completion of all critical fields. Additionally, there is a need for increased socialization, regular supervision, and ongoing training for health workers to achieve 100% completeness standards. Optimizing the electronic DSF is expected to improve hospital service quality, medical documentation, and the efficiency of digital healthcare services in meeting legal and accreditation standards.