Routine Socialization and Training

Oct 13, 2025 by wbrum.org 57 views

The Influence of Individual and Psychological Characteristics on the Performance of Nurses in the Completeness of Medical Records in the Inpatient Room of the General Hospital Dr. Pirngadi Medan

Introduction

The completeness of medical records is a crucial aspect of healthcare, particularly in hospitals. Inadequate or incomplete medical records can lead to misdiagnosis, delayed treatment, and even patient harm. The General Hospital Dr. Pirngadi Medan, in Medan, Indonesia, has been facing challenges in ensuring the completeness of medical records. In 2007, the hospital's data showed that only 11.81% of medical records were returned on time, and the level of completeness of the contents of the medical record was only 40.6%. This situation highlights the need to investigate the factors influencing the performance of nurses in completing medical records.

Background

The General Hospital Dr. Pirngadi Medan is a major healthcare institution in Medan, providing a wide range of medical services to patients. The hospital's inpatient room is one of the busiest areas, with a large number of patients being admitted and discharged daily. The nurses working in this area play a critical role in ensuring the completeness of medical records. However, the hospital's data suggests that the nurses are facing challenges in fulfilling this responsibility.

Research Objectives

This study aims to investigate the influence of individual and psychological characteristics of nurses on their performance in completing medical records in the inpatient room of the General Hospital Dr. Pirngadi Medan. The study uses a survey method with an explanatory approach to gather data from a sample of 75 nurses working in the inpatient room.

Methodology

The research population consists of all implementing nurses who are civil servants and served in the inpatient room of Dr. Pirngadi Medan. A total of 75 nurses were chosen as samples through simple random sampling techniques. The data were analyzed using multiple linear regression tests with a 95% confidence level.

Results

The results of the study showed that knowledge (p = 0.042) and motivation (p = 0.049) had a significant influence on the performance of nurses in completing medical records. This means that nurses with high knowledge and motivation tend to have better performance in filling medical records. On the other hand, variables such as age (p = 0.794), gender (p = 0.298), length of work (p = 0.588), and attitude (p = 0.389) had no significant influence on the performance of nurses in the completeness of medical records.

Discussion

The findings of this study indicate that increasing nurses' knowledge and motivation is the main key in increasing the completeness of medical records. Hospital management and medical records need to make strategic efforts to increase the knowledge and motivation of nurses. Some of the strategies that can be implemented include:

Routine Socialization and Training: Providing regular training and socialization on the correct and complete filling of medical records.
Increasing access to information and learning resources: Providing nurses with access to information and learning resources related to filling medical records.
Creation of appreciation and recognition systems: Creating systems to appreciate and recognize nurses who have good performance in the completeness of medical records.
Provision of motivation: Providing nurses with motivation such as appreciation and appreciation, as well as creating a positive and supportive work environment.

Conclusion

The completeness of medical records is a critical aspect of healthcare, and nurses play a vital role in ensuring its accuracy and completeness. The findings of this study suggest that increasing nurses' knowledge and motivation is the main key in increasing the completeness of medical records. Hospital management and medical records need to make strategic efforts to increase the knowledge and motivation of nurses. By implementing the strategies mentioned above, it is expected that the completeness of medical records at Dr. Pirngadi Medan can increase, leading to better quality of health services and patient data management.

Recommendations

Based on the findings of this study, the following recommendations are made:

Hospital management and medical records should prioritize increasing nurses' knowledge and motivation.
Regular training and socialization on the correct and complete filling of medical records should be provided.
Nurses should be provided with access to information and learning resources related to filling medical records.
Systems to appreciate and recognize nurses who have good performance in the completeness of medical records should be created.
Nurses should be provided with motivation such as appreciation and appreciation, as well as creating a positive and supportive work environment.

Limitations

This study has some limitations. The sample size is relatively small, and the study only focuses on the inpatient room of the General Hospital Dr. Pirngadi Medan. Future studies should aim to increase the sample size and include other departments and hospitals.

Future Research Directions

Future research should aim to investigate the factors influencing the performance of nurses in completing medical records in other hospitals and departments. Additionally, studies should focus on developing and implementing effective strategies to increase nurses' knowledge and motivation.

References

[Insert references cited in the study]

Appendix

[Insert appendix materials, such as additional tables and figures]
Frequently Asked Questions (FAQs) about the Influence of Individual and Psychological Characteristics on the Performance of Nurses in the Completeness of Medical Records

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

A: Medical records are a crucial aspect of healthcare, as they contain vital information about a patient's medical history, diagnosis, treatment, and outcomes. Accurate and complete medical records are essential for providing high-quality patient care, ensuring continuity of care, and preventing medical errors.

Q: What are the challenges faced by nurses in completing medical records?

A: Nurses face several challenges in completing medical records, including lack of knowledge and understanding of medical record-keeping procedures, inadequate training and support, and heavy workload and time constraints.

Q: What are the individual and psychological characteristics that influence the performance of nurses in completing medical records?

A: The study found that knowledge and motivation are the two individual and psychological characteristics that significantly influence the performance of nurses in completing medical records. Nurses with high knowledge and motivation tend to have better performance in filling medical records.

Q: What are the strategies that can be implemented to increase nurses' knowledge and motivation?

A: Some of the strategies that can be implemented to increase nurses' knowledge and motivation include:

Routine socialization and training on the correct and complete filling of medical records
Increasing access to information and learning resources related to filling medical records
Creation of appreciation and recognition systems for nurses who have good performance in the completeness of medical records
Provision of motivation such as appreciation and appreciation, as well as creating a positive and supportive work environment

Q: What is the role of hospital management and medical records in increasing nurses' knowledge and motivation?

A: Hospital management and medical records play a critical role in increasing nurses' knowledge and motivation. They should prioritize providing regular training and socialization on the correct and complete filling of medical records, increasing access to information and learning resources, and creating appreciation and recognition systems for nurses who have good performance in the completeness of medical records.

Q: What are the benefits of increasing nurses' knowledge and motivation in completing medical records?

A: Increasing nurses' knowledge and motivation in completing medical records can lead to several benefits, including:

Improved accuracy and completeness of medical records
Enhanced patient care and outcomes
Reduced medical errors and adverse events
Increased job satisfaction and engagement among nurses

Q: What are the limitations of this study?

A: This study has some limitations, including a relatively small sample size and a focus on the inpatient room of the General Hospital Dr. Pirngadi Medan. Future studies should aim to increase the sample size and include other departments and hospitals.

Q: What are the future research directions for this study?

A: Future research should aim to investigate the factors influencing the performance of nurses in completing medical records in other hospitals and departments. Additionally, studies should focus on developing and implementing effective strategies to increase nurses' knowledge and motivation.

Q: How can nurses and healthcare organizations implement the strategies mentioned in this study?

A: Nurses and healthcare organizations can implement the strategies mentioned in this study by:

Prioritizing regular training and socialization on the correct and complete filling of medical records
Increasing access to information and learning resources related to filling medical records
Creating appreciation and recognition systems for nurses who have good performance in the completeness of medical records
Providing motivation such as appreciation and appreciation, as well as creating a positive and supportive work environment

Q: What are the implications of this study for healthcare policy and practice?

A: This study has implications for healthcare policy and practice, including the need to prioritize increasing nurses' knowledge and motivation in completing medical records. Healthcare organizations should develop and implement effective strategies to support nurses in this area, and policymakers should consider the findings of this study when developing healthcare policies and regulations.