The Contributing Factors Of Medical Records Completeness At Inpatient Ward In RSUD of Sumedang District Year 2011

The Contributing Factors Of Medical Records Completeness At Inpatient Ward

Abstract

One of the vital information for SIRS is medical records. Medical records must be filled correctly and
completely becauseitcontain vital information that covers administrative, legal, financial and clinical aspects. At
Sumedang District Hospital in 2010, 74.8% inpatient medical records werefilled partly.The aim of this study isto
analyze the completeness of medical records at inpatient ward and the contributing factors. A mixed methods
sequential explanatory research had been used.It started with a quantitative research for385medical records,
followed by a qualitative research to describe the findings. Subjects consist of health officers from inpatient
ward and hospital managers, totalling13 people. The results showed that 58,4% inpatient medical records were
incomplete. This results consist of 23,9% Medical Resume, 30,3% Operation Report, 18,2% Identification of
Infants and 14.9% Labor Report. The contributing factors are input factor(lack of technical knowledge, negative
attitudes, inadequatefacilities, SOP, and socialization) and process factor (SOP, difference in treatment,
monitoring and evaluation system not optimaland incoherent teamwork). The completeness of medical records
can be improved by evaluating and monitoring the aforementioned factor.
Keywords: completeness, medical record, inpatient ward.