Analysis of Completeness of Inpatient Medical Record Files in the ICU at the BLUD Baubau City Hospital

Abstract

Medical records serve to provide health information for medical personnel caring for patients. One important indicator in medical record services is the completeness of the files, which must be filled out completely with a standard of 100%. This study aims to analyze the completeness of inpatient medical record files using a descriptive quantitative method. The study population consisted of 348 inpatient medical records in the ICU in 2024, with a sample of 78 medical records taken using the Slovin formula. The results showed that in the identification component, all items in the 78 medical records were filled out completely (100%). In the vital report component, the highest level of completeness was found in the main diagnosis, discharge status, admission date, and discharge date, all of which were complete in 78 files (100%). The lowest level of completeness was found in the procedure consent form, with only 37 files (47%). In the authentication component, the medical history had the highest level of completeness with 73 files (94%), while the procedure consent had the lowest level of completeness with 44 files (56%). In the good and correct record component, the most correct writing was found in the patient's main diagnosis with 78 files (100%). In contrast, patient name spelling had the lowest accuracy rate, with only 29 records (37%) being correct, while 49 records (63%) contained spelling errors. This study emphasizes the importance of completing complete and accurate medical records to support optimal healthcare delivery.

Medical records serve to provide health information for medical personnel treating patients. One important indicator in medical record services is the completeness of files, which must be filled out completely with a standard of 100%. This study aims to analyze the completeness of inpatient medical record files using a descriptive quantitative method. The study population consisted of 348 inpatient medical records in the ICU in 2024, with a sample of 78 records taken using the Slovin formula. The results showed that in the identification component, all items in the 78 records were completely filled out (100%). In the important report component, the highest completeness was found in the main diagnosis, discharge status, admission date, and discharge date, all of which were complete in 78 files (100%). The lowest completeness was found in the procedure consent form, with only 37 files (47%) being complete. In the authentication component, medical resumes had the highest completeness with 73 files (94%), while procedure consent had the lowest with 44 files (56%). In the component of good and correct records, the most correct writing was found in the patient's main diagnosis with 78 files (100%). Conversely, the writing of patient names was the lowest, with only 29 files (37%) being correct, while 49 files (63%) contained writing errors. This study emphasizes the importance of completing medical record files completely and accurately to support optimal health services.