Faktor Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Rawat Inap di Rumah Sakit Universitas Muhammadiyah Malang Factors Affecting Incomplete Inpatient Medical Record Completion at Muhammadiyah University Hospital Malang
One of the efforts to improve the quality of health care facilities is to improve the service quality of medical records including completeness, speed, and accuracy in providing information to health care needs. Complete and accurate medical records can be used as a healthcare reference, legal basis (medico legal) supporting information to improve medical information quality, medical research, and as the basis of assessing hospital performance. The objective of the study was to determine the factors that affect the incompleteness of inpatient medical record at Muhammadiyah University Hospital (UMM Hospital) Descriptive analysis was used to analyze the data, while data collection was done through interview, observation, and document study. The study has been conducted among 40 unassembled inpatient medical record documents, while interview was done to the relevant officers to determine the factors that cause the incompleteness of medical record documents. The observation was carried out to complete the interview section, whereas, the document study showed that the number of incomplete medical record was 100% that mostly performed by doctors. Both interview and observation found that there were absence of policies, guidelines and SOP on completing medical records, low awareness of physicians to fill medical records, the absence of medical record incompleteness data, monitoring and evaluation system of ineffective medical records, and unstandardized pathway of inpatient medical record file. As a solution to improve the completeness of the medical record, creating policies, guidelines, and SOP about completing the medical record are needed.