Completeness of Inpatient Medical Record Documents at the Islamic Hospital, Surakarta Regency

Abstract

Medical records are essential documents that record the history of patient healthcare services and function in administrative, clinical, legal, and accreditation aspects. This study aims to explain the completeness of inpatient medical record documentation based on service standards at Rumah Sakit Islam Surakarta and to identify the influencing factors.This research used a descriptive qualitative method with a case study approach. Data were obtained through observation of 60 inpatient medical record documents from class II and III, and interviews with the head and staff of the medical records unit. The results showed that the physical examination and informed consent components had the highest completeness level (100%), while other services such as dental cases had only 45%. Influencing factors included the absence of a completeness checklist, suboptimal SOP socialization, and the lack of strict internal regulations. This study recommends regular training, consistent supervision, and the use of electronic medical records to improve the quality and completeness of medical record documentation.