Journal of Health and Medical Sciences
Published: 28 June 2023
Analysis of Completeness of Filling in Medical Records in Inpatients of Orthopedic Surgery to Improve Quality Services at Hasan Sadikin Hospital Bandung, Indonesia
Beni Gunawan, Dodi Syaripudin
Piksi Ganesha Polytechnic, Indonesia
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Keywords: Hospitalization, Medical records, Service Quality
This study aimed to find out how to implement filling out the medical records for orthopedic surgery at Hasan Sadikin General Hospital, Bandung. The research was conducted using a qualitative descriptive method, namely analyzing and describing the data and explaining the results obtained in full on the completeness of the medical record. The results showed that filling out the medical record form was incomplete with a population of 139 Delinquent Medical Record (DMR) samples; 54 DMR were taken. The highest incomplete form in the Authentication Review, namely "Nursing Assessment," there were 12(22%) complete 42(78%) incomplete; the highest incomplete form in the Reporting Review, namely "Medication Notes," there were 13(24%) complete 41(76%) incomplete. Incomplete medical record filling includes (1) The level of understanding of nurses and doctors on the importance of filling out medical records, (2) Doctors' delays and limitations on practice time, (3) Doctors and nurses' busyness levels, (4) Doctors' dependence on nurses, (5) the lack of attention of doctors and nurses towards filling out medical records. Suggestions for assembling officers to be more focused and pay attention to their work so that medical record documents with incomplete contents can be controlled and controlled periodically so that medical record documents are better with lower DMR numbers on filling.
Alfiansyah, G., Mulia, A. N. E., Wijayanti, R. A., & Sabran, S. (2022). Incomplete Inpatient Medical Record Documents at Hospital. Jurnal Aisyah : Jurnal Ilmu Kesehatan, 7(4), 1195–1200. https://doi.org/10.30604/jika.v7i4.1349
Ayaad, O., Alloubani, A., ALhajaa, E. A., Farhan, M., Abuseif, S., Al Hroub, A., & Akhu-Zaheya, L. (2019). The role of electronic medical records in improving the quality of health care services: Comparative study. International Journal of Medical Informatics, 127(January), 63–67. https://doi.org/10.1016/j.ijmedinf.2019.04.014
Binarti, I., & Fitriyana, F. D. (2022). Analysis of Incomplete Medical Record Filling in Indonesia. International Journal of Science and Society, 4(1), 347–357. https://doi.org/10.54783/ijsoc.v4i1.441
Campbell, S., Greenwood, M., Prior, S., Shearer, T., Walkem, K., Young, S., Bywaters, D., & Walker, K. (2020). Purposive sampling: complex or simple? Research case examples. Journal of Research in Nursing, 25(8), 652–661. https://doi.org/10.1177/1744987120927206
Haryanti, S. (2022). Penyusutan Arsip Rekam Medis Di Rumah Sakit:Studi Kasus Rumah Sakit Vertikal Kemenkes [Shrinkage of Medical Record Archives in Hospitals: A Case Study of the Ministry of Health's Vertical Hospital]. Jurnal Vokasi Indonesia, 10(2). https://doi.org/10.7454/jvi.v10i2.1016
Jim, H. S. L., Hoogland, A. I., Brownstein, N. C., Barata, A., Dicker, A. P., Knoop, H., Gonzalez, B. D., Perkins, R., Rollison, D., Gilbert, S. M., Nanda, R., Berglund, A., Mitchell, R., & Johnstone, P. A. S. (2020). Innovations in research and clinical care using patient‐generated health data. CA: A Cancer Journal for Clinicians, 70(3), 182–199. https://doi.org/10.3322/caac.21608
Manzoor, F., Wei, L., Hussain, A., Asif, M., & Shah, S. I. A. (2019). Patient satisfaction with health care services; an application of physician’s behavior as a moderator. International Journal of Environmental Research and Public Health, 16(18), 1–16. https://doi.org/10.3390/ijerph16183318
Rizkika, M. Y. (2020). Analisis Kuantitatif Kelengkapan Dokumen Rekam Medis Pasien Rawat Inap Dengan Diagnosa Fracture Femur Di RSUD Dr. R.M. Djoelham Binjai [Quantitative Analysis of the Completeness of Medical Record Documents for Inpatients with a Diagnosis of Femur Fracture at RSUD Dr. R.M. Djoelham Binjai]. 5(1), 62–71.
Rumana, N. A., Aprilia, R. M., Dewi, D. R., Indawati, L., Yulia, N., & Viatiningsih, W. (2020). Does The Medical Record Graduates Have More Competence Than The Non-Medical. 5, 189–193.
Saiedeh Sharifi, M. Z., Dargahi, H., & Faraji‑Khiavi, F. (2023). Medical record documentation quality in the hospital accreditation. Journal of Education and Health Promotion, 12(February). https://doi.org/10.4103/jehp.jehp
Surucu, L., & Maslakci, A. (2020). Validity and reliability in quantitative research. Business & Management Studies: An International Journal, 8(3), 2694–2726.