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

Aqilah Asyah Pradana Aqilah; Nahardian Vica Rahmawati; Enny Mar’atus

doi:10.62354/jurnalmedicare.v5i4.621

Penulis

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

Abstrak

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

Unduhan

Data unduhan belum tersedia.

Kata Kunci:

completeness, documentation, inpatient, medical records, quality

Referensi

Anggraeni, A., & Herlina, I. (2022). Analysis of the completeness of inpatient medical record documentation at Cikalong Wetan Regional General Hospital. Jurnal Bidang Ilmu Kesehatan, 12(1). https://doi.org/10.52643/jbik.v12i1.1580

Anugrah, A., & Umar, Z. (2023). Analysis of the completeness of inpatient medical record documents at I.A. Moeis Regional General Hospital, Samarinda. Jurnal Pengabdian Kepada Masyarakat Nusantara, 4(3), 2508–2512. https://doi.org/10.55338/jpkmn.v4i3.1474

Lewis, A. E., Weiskopf, N., Abrams, Z. B., Foraker, R., Lai, A. M., Payne, P. R. O., & Gupta, A. (2023). Electronic health record data quality assessment and tools: A systematic review. Journal of the American Medical Informatics Association, 30(10), 1730–1740. https://doi.org/10.1093/jamia/ocad120

Masyfufah, L., Listiawan, N., Yulianita, N. E., Wahyuni, T., Sutha, D. W., & Pribadi, M. S. W. (2024). Completeness of electronic medical record documentation for patients at general outpatient clinics in East Surabaya Community Health Centers. Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda, 9(2), 177–188. https://doi.org/10.52943/jipiki.v9i2.1689

Ozonze, O., Scott, P. J., & Hopgood, A. A. (2023). Automating electronic health record data quality assessment. Journal of Medical Systems, 47, 23. https://doi.org/10.1007/s10916-022-01892-2

Scarpis, E., Brunelli, L., Tricarico, P., Poletto, M., Panzera, A., Londero, C., Castriotta, L., & Brusaferro, S. (2021). How to assure the quality of clinical records? A 7-year experience in a large academic hospital. PLOS ONE, 16(12), e0261018. https://doi.org/10.1371/journal.pone.0261018

Sharifi, S., Zahiri, M., Dargahi, H., & Faraji-Khiavi, F. (2021). Medical record documentation quality in the hospital accreditation. Journal of Education and Health Promotion, 10, 76. https://doi.org/10.4103/jehp.jehp_852_20

Wurster, F., Beckmann, M., Cecon-Stabel, N., Dittmer, K., Hansen, T. J., Jaschke, J., Köberlein-Neu, J., Okumu, M.-R., Pfaff, H., Rusniok, C., & Karbach, U. (2024). The implementation of an electronic medical record in a German hospital and the change in completeness of documentation: Longitudinal document analysis. JMIR Medical Informatics, 12, e47761. https://doi.org/10.2196/47761

Wurster, F., Herrmann, C., Beckmann, M., et al. (2024). Differences in changes of data completeness after the implementation of an electronic medical record in three surgical departments of a German hospital. BMC Medical Informatics and Decision Making, 24, 258. https://doi.org/10.1186/s12911-024-02667-0

Zabolinezhad, H., Eslami, S., Hassibian, M. R., & Dorri, S. (2022). Assessing the quality of electronic medical records in academic hospitals: A multi-center study in Iran. Frontiers in Digital Health, 4, 856010. https://doi.org/10.3389/fdgth.2022.856010

Al Aufa, B., Nuryanti, E., & Susilawati. (2023). Assessment of medical record document completeness in inpatient units before and after STARKES accreditation in a private hospital. Proceedings of ICVEAST 2023. https://doi.org/10.2991/978-2-38476-132-6_4

Fauzan, A., Wahyudi, A., & Zaman, C. A. (2024). Analysis of the completeness of patient medical record documentation. Jurnal 'Aisyiyah Medika, 9(2). https://garuda.kemdiktisaintek.go.id/documents/detail/4408739

Putri, A. K., Nurmawati, I., Santi, M. W., & Swari, S. J. (2022). Factors contributing to incomplete medical record documentation for hospitalized patients. Jurnal Penelitian Kesehatan Suara Forikes, 13(1), 894–901.

Senja, S. M. A., & Romodon, D. (2024). The effect of the completeness of electronic inpatient medical summaries on the accuracy of medical record quality at Purwokerto Islamic Hospital. Procedia of Engineering and Life Science, 6, 103–106. https://doi.org/10.21070/pels.v6i1.1937

Republic of Indonesia. (2023). Law of the Republic of Indonesia Number 17 of 2023 concerning Health.

Republic of Indonesia Ministry of Health. (2022). Regulation of the Minister of Health of the Republic of Indonesia Number 24 of 2022 concerning Medical Records.