Determinant Completeness of Medical Records of Inpatient Patients Four Basic Specialization at Madani General Hospital Medan in 2017

Oct 13, 2025 by wbrum.org 124 views

Determinant Completeness of Medical Records of Inpatient Patients Four Basic Specialization at Madani General Hospital Medan in 2017

Introduction

Medical records are a crucial component of healthcare services in hospitals, serving as a vital source of information for determining further medical actions. At Medan Madani General Hospital, this study aimed to identify the factors influencing the completeness of medical records of inpatients in four basic specializations in 2017. The study employed a qualitative approach, involving observation of 32 patient medical record files and in-depth interviews with 11 informants, including eight basic specialist doctors, the head of medical record units, heads of inpatient rooms, and management.

The Importance of Medical Records

Medical records are a vital tool for healthcare providers, containing essential information about patients that informs further medical actions. The completeness of medical records is critical in ensuring that patients receive quality care. In Indonesia, the Minister of Health Regulation No. 269/Menkes/Per/III/2008 outlines the provisions for medical records, emphasizing the importance of completeness in medical record-keeping.

Analysis of Determinant Factors for Completeness of Medical Records

Several determinant factors were identified as influencing the completeness of medical records. Firstly, the doctor's knowledge of the benefits of medical records plays a significant role. Doctors who understand the importance of medical records in providing quality services tend to be more thorough in filling. Additionally, sanctions related to incomplete medical records stipulated in RI Law No. 29 of 2004 concerning Medical Practice serve as a motivational factor for doctors to complete medical records correctly.

Secondly, the discipline of doctors in carrying out their duties also plays an important role. Disciplined doctors are more likely to meet all the provisions in filling medical records. However, limited time and the number of patients to be handled often become obstacles. In situations where doctors have to handle many patients in a short time, the risk of incomplete medical record data is higher.

The Role of Doctor's Knowledge and Discipline

The doctor's knowledge of the benefits of medical records is a critical determinant factor in ensuring the completeness of medical records. Doctors who understand the importance of medical records in providing quality services tend to be more thorough in filling. This knowledge is essential in motivating doctors to complete medical records correctly.

Furthermore, the discipline of doctors in carrying out their duties also plays an important role. Disciplined doctors are more likely to meet all the provisions in filling medical records. However, limited time and the number of patients to be handled often become obstacles. In situations where doctors have to handle many patients in a short time, the risk of incomplete medical record data is higher.

The Impact of Limited Time and Number of Patients

Limited time and the number of patients to be handled often become obstacles in ensuring the completeness of medical records. In situations where doctors have to handle many patients in a short time, the risk of incomplete medical record data is higher. This highlights the need for hospital management to provide guidance and training to health workers about the importance of medical records.

Recommendations for Increasing the Completeness of Medical Records

Based on the results of the study, several recommendations are made to hospital management to increase the completeness of medical records. Firstly, hospital management should provide guidance and training to health workers about the importance of medical records. Clear policies and technical socialization of filling medical records are also needed to ensure that each officer understands the process and the importance of the completeness of the data.

Secondly, the addition of health workers, especially doctors in four basic specializations, can be a solution to reduce the workload of doctors so that the time available for filling medical records is more adequate. With these steps, it is expected that the completeness of the medical record of inpatients at Medan Madani General Hospital can be increased, which in turn will support better quality health services.

Conclusion

In conclusion, the completeness of medical records is a critical component of healthcare services in hospitals. The study identified several determinant factors influencing the completeness of medical records, including the doctor's knowledge of the benefits of medical records and the discipline of doctors in carrying out their duties. Recommendations were made to hospital management to increase the completeness of medical records, including providing guidance and training to health workers and adding health workers to reduce the workload of doctors. With these steps, it is expected that the completeness of the medical record of inpatients at Medan Madani General Hospital can be increased, which in turn will support better quality health services.

Limitations of the Study

This study has several limitations. Firstly, the study was conducted in a single hospital, Medan Madani General Hospital, which may limit the generalizability of the findings. Secondly, the study employed a qualitative approach, which may not provide a comprehensive understanding of the determinant factors influencing the completeness of medical records. Finally, the study did not explore the impact of technology on the completeness of medical records.

Future Research Directions

Future research should aim to explore the impact of technology on the completeness of medical records. With the increasing use of electronic health records, it is essential to understand how technology can support or hinder the completeness of medical records. Additionally, future research should aim to explore the impact of hospital management policies on the completeness of medical records. By understanding the factors influencing the completeness of medical records, hospital management can develop effective strategies to improve the quality of healthcare services.

References

Minister of Health Regulation No. 269/Menkes/Per/III/2008
RI Law No. 29 of 2004 concerning Medical Practice
Various studies on the importance of medical records in healthcare services
Frequently Asked Questions (FAQs) about Determinant Completeness of Medical Records of Inpatient Patients Four Basic Specialization at Madani General Hospital Medan in 2017

Q: What is the importance of medical records in healthcare services?

A: Medical records are a crucial component of healthcare services in hospitals, serving as a vital source of information for determining further medical actions. The completeness of medical records is critical in ensuring that patients receive quality care.

Q: What are the determinant factors influencing the completeness of medical records?

A: Several determinant factors were identified as influencing the completeness of medical records, including the doctor's knowledge of the benefits of medical records and the discipline of doctors in carrying out their duties.

Q: What is the role of doctor's knowledge in ensuring the completeness of medical records?

A: The doctor's knowledge of the benefits of medical records is a critical determinant factor in ensuring the completeness of medical records. Doctors who understand the importance of medical records in providing quality services tend to be more thorough in filling.

Q: What is the impact of limited time and number of patients on the completeness of medical records?

A: Limited time and the number of patients to be handled often become obstacles in ensuring the completeness of medical records. In situations where doctors have to handle many patients in a short time, the risk of incomplete medical record data is higher.

Q: What are the recommendations for increasing the completeness of medical records?

A: Based on the results of the study, several recommendations are made to hospital management to increase the completeness of medical records, including providing guidance and training to health workers about the importance of medical records and adding health workers to reduce the workload of doctors.

Q: What are the limitations of the study?

A: This study has several limitations, including the study being conducted in a single hospital, Medan Madani General Hospital, which may limit the generalizability of the findings. Additionally, the study employed a qualitative approach, which may not provide a comprehensive understanding of the determinant factors influencing the completeness of medical records.

Q: What are the future research directions?

A: Future research should aim to explore the impact of technology on the completeness of medical records. With the increasing use of electronic health records, it is essential to understand how technology can support or hinder the completeness of medical records. Additionally, future research should aim to explore the impact of hospital management policies on the completeness of medical records.

Q: What are the implications of the study for hospital management?

A: The study highlights the need for hospital management to provide guidance and training to health workers about the importance of medical records. Additionally, hospital management should consider adding health workers to reduce the workload of doctors and improve the completeness of medical records.

Q: What are the benefits of improving the completeness of medical records?

A: Improving the completeness of medical records can lead to better quality healthcare services, improved patient outcomes, and reduced medical errors. Additionally, complete medical records can facilitate communication between healthcare providers and improve the continuity of care.

Q: How can healthcare providers ensure the completeness of medical records?

A: Healthcare providers can ensure the completeness of medical records by following established guidelines and protocols for medical record-keeping. Additionally, healthcare providers should prioritize the importance of medical records and make them a priority in their daily work.

Q: What are the consequences of incomplete medical records?

A: Incomplete medical records can lead to medical errors, delayed diagnosis, and poor patient outcomes. Additionally, incomplete medical records can compromise the continuity of care and hinder communication between healthcare providers.

Q: How can hospital management support the completeness of medical records?

A: Hospital management can support the completeness of medical records by providing guidance and training to health workers about the importance of medical records. Additionally, hospital management should consider adding health workers to reduce the workload of doctors and improve the completeness of medical records.