Analysis Of Medical Record File Completeness At Kampeonaho Public Health Center

Abstract

Background: completeness of medical record documentation is a crucial aspect to ensure service quality, legal certainty, and the availability of accurate health data in primary healthcare centers. Objective: this study aimed to analyze the completeness of outpatient medical record files at Kampeonaho Health Center in 2025. Method: a quantitative descriptive method was employed, with a sample of 77 files out of a total of 327 records selected using a simple random sampling technique. Four components were assessed, namely patient identification, essential reports, authentication, and proper documentation. The results indicated that patient identification componentsincluding name, medical record number, address, and date of birthwere fully completed (100%), whereas the age field showed 2.59% incompleteness. In the essential reports, general consent and visit date were fully documented (100%), while complaint and diagnosis fields had an incompleteness rate of 5.19% each. Authentication by doctors and nurses was 97.40% complete. In terms of documentation, legibility was high (93.50%), but correction entries were relatively low (55.84%). Conclusion: Overall, the completeness of medical records at Kampeonaho Health Center has shown satisfactory results, yet deficiencies remain in authentication and correction documentation. Therefore, enhanced discipline and training for healthcare personnel are necessary to improve the accuracy of medical records and strengthen the quality of healthcare services.