Analysis of Compliance and Knowledge Factors Regarding the Completeness of Medical Records

Alfita Dewi, Ilmu Nuria Sulrieni, Masdalena Masdalena

Abstract


Incomplete medical records are one of the problems because medical records are data records that can provide information about actions in patients. The purpose of this study was to determine the factors that affect the completeness of filling inpatient medical records at RSUD dr. Rasidin Padang. This type of research is quantitative research with an observative approach. The sample in this study was 165 medical record files and 43 officers in charge of filling out medical records. The data collection method uses questionnaires and checklist tables. The variables studied were incompleteness of medical records, adherence factors, motivational factors, attitude factors and knowledge factors. The results of the study were from 165 completeness of filling medical records at RSUD dr. Rasidin Padang, there were 90 (54.5) incomplete files in filling medical records, judging from 43 respondents in compliance factors there were 10 (23.3) respondents who did not comply, motivation factors there were 16 (37.2) respondents who were not well motivated, Attitude factor there were 7 (16.3) respondents who had bad attitudes and in knowledge factor there were 14 (32.6) respondents who were not well informed. Judging from these 5 components, in general, Dr. Rasidin Padang Hospital has nothing to do with the completeness of filling out medical records because the data obtained in the questionnaire many officers fill out which is fine, in fact there are still many documents that are complete, filling out medical records is still incomplete.

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