ANALYSIS OF COMPLETENESS OF CASE STUDY PATIENT MEDICAL RECORDS IN THE MEDICAL RECORD LABORATORY OF STIKES RS BAPTIS KEDIRI IN 2024

Abstract

Medical Record Laboratory is a practicum area engaged in the service area; therefore, it is mandatory to organize medical records to achieve good administration. Registration, data entry, processing and analysis and documentation, these are the processes of organizing medical records. Filling out medical records is said to be good if each item on the medical record sheet is filled with complete data. Complete medical records are a quality image of a hospital. The purpose of this study was to determine a general description of analysis completeness of case study medical records on patient identity, anamnesis, informed consent, medical resumes in patients at Medical Record Laboratory of STIKES RS Baptis Kediri in 2024. The type of research used was descriptive research. The sample in this study was a case study medical record file of 42 medical records. The instrument used was a checklist sheet. Data analysis used univariate analysis. The results of the study obtained a percentage of completeness for patient identity medical records of 97.6%, anamnesis of 95.2%, informed consent of 100%, medical resume of 100%. It was expected that medical records officers need to have awareness and discipline in completing medical records through good cooperation between nurses and the doctors concerned.