ANALYSIS OF THE COMPLETENESS OF MEDICAL RECORD DOCUMENTATION AT JANNATUL MA’WA INPATIENT WARD, MUHAMMADIYAH BABAT GENERAL HOSPITAL

Authors

  • Aqilah Asyah Pradana Aqilah Muhammadiyah University of Lamongan
  • Nahardian Vica Rahmawati Muhammadiyah University of Lamongan
  • Enny Mar’atus Muhammadiyah University of Lamongan

DOI:

https://doi.org/10.62354/jurnalmedicare.v5i4.621

Abstract

Background: Completeness of medical record documentation is important for continuity of care, patient safety, quality
assurance, and legal accountability.Aims: This study aimed to analyze the completeness of inpatient medical record
documentation at Jannatul Ma’wa Inpatient Ward, Muhammadiyah Babat General Hospital.Methods: This
quantitative descriptive study was conducted in August 2026 at Muhammadiyah Babat General Hospital. The
population consisted of 256 inpatient medical records from July 2026, with 40 records selected using non-probability
accidental sampling. Data were collected through observation using a checklist covering patient progress notes,
consultation results, medical informed consent, discharge summary, and patient condition at discharge. Data were
analyzed descriptively using frequencies and percentages.Result: All five assessed components showed 100%
completeness (40 records) and 0% incompleteness: patient progress notes, consultation results, medical informed
consent, discharge summary, and patient condition at discharge.Conclusion: All assessed inpatient medical records
met the completeness indicators used in this study. Routine monitoring and evaluation should be maintained to
preserve the consistency and timeliness of documentation.
Keywords: completeness; documentation; inpatient; medical records; quality

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Keywords:

completeness, documentation, inpatient, medical records, quality

References

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Published

2026-11-02

How to Cite

Aqilah, A. A. P., Nahardian Vica Rahmawati, & Enny Mar’atus. (2026). ANALYSIS OF THE COMPLETENESS OF MEDICAL RECORD DOCUMENTATION AT JANNATUL MA’WA INPATIENT WARD, MUHAMMADIYAH BABAT GENERAL HOSPITAL . Jurnal Medicare, 5(4). https://doi.org/10.62354/jurnalmedicare.v5i4.621

Issue

Vol. 5 No. 4 (2026): OCTOBER 2026

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