Published Paper Details:

Completeness of medical records is very useful for knowing in detail the patient's history, examination actions that have been carried out, and planning further actions. To achieve this, the medical record department is obliged to carry out quality monitoring by conducting quantitative, qualitative, and statistical analyses. Knowing the complete and incomplete of a medical record file needs to be analyzed quantitatively Medical records must be completed immediately after the patient receives service. Completeness of filling in inpatient medical records must be achieved within 24 hours. This is done on an ongoing basis so that the quality of the files is maintained and the quality of the hospital can be improved. Reksodiwiryo Padang City to know the incompleteness of inpatient medical record files, especially in surgical cases by looking at the four components. This research will be carried out in September-October 2021 by looking at the medical record file and looking for incompleteness in the former. This research method is descriptive qualitative, while the method used is the observation method, looking at objects directly with a retrospective approach, looking at existing data. The population of this study was all medical record files of inpatients at TK III Dr. Reksodiwiryo in surgical cases in the first quarter of 2020. The result is the highest percentage of the identification component is the birthdate item at 94.29%, and the highest percentage of incompleteness is found in the gender item, which is 77.14%. The highest percentage of the completeness of the important report components was obtained on the patient progress record form of 98.6%, only one form did not have a patient progress record. The highest percentage of incompleteness obtained on the informed consent form is 27.14%. The highest percentage of the completeness of the authentication component is obtained for the doctor's name item by 69% and the nurse's title item is 100% incomplete. The percentage of incompleteness in the components of the recording method is the highest inCompleteness of medical records is very useful for knowing in detail the patient's history, examination actions that have been carried out, and planning further actions. To achieve this, the medical record department is obliged to carry out quality monitoring by conducting quantitative, qualitative, and statistical analyses. Knowing the complete and incomplete of a medical record file needs to be analyzed quantitatively Medical records must be completed immediately after the patient receives service. Completeness of filling in inpatient medical records must be achieved within 24 hours. This is done on an ongoing basis so that the quality of the files is maintained and the quality of the hospital can be improved. Reksodiwiryo Padang City to know the incompleteness of inpatient medical record files, especially in surgical cases by looking at the four components. This research will be carried out in September-October 2021 by looking at the medical record file and looking for incompleteness in the former. This research method is descriptive qualitative, while the method used is the observation method, looking at objects directly with a retrospective approach, looking at existing data. The population of this study was all medical record files of inpatients at TK III Dr. Reksodiwiryo in surgical cases in the first quarter of 2020. The result is the highest percentage of the identification component is the birthdate item at 94.29%, and the highest percentage of incompleteness is found in the gender item, which is 77.14%. The highest percentage of the completeness of the important report components was obtained on the patient progress record form of 98.6%, only one form did not have a patient progress record. The highest percentage of incompleteness obtained on the informed consent form is 27.14%. The highest percentage of the completeness of the authentication component is obtained for the doctor's name item by 69% and the nurse's title item is 100% incomplete. The percentage of incompleteness in the components of the recording method is the highest in the abbreviated item of 91.4%. In the medical record file, there are almost no abbreviations for diagnosis on the form. The highest percentage of incompleteness is found in the blank section of 57.14%. the abbreviated item of 91.4%. In the medical record file, there are almost no abbreviations for diagnosis on the form. The highest percentage of incompleteness is found in the blank section of 57.14%.