Published Paper Details:

According to the Minister of Health Regulation Number 269/MENKES/PER/III/ 2008, the requirements for a quality medical record are related to the completeness of medical record entries, accuracy, accuracy of medical records, punctuality and fulfillment of legal aspect requirements. Based on the Decree of the Minister of Health of the Republic of Indonesia No.129/Menkes/SK/II/2008 concerning Hospital Minimum Service Standards (SPM), which contains information about hospital medical record services, namely completing medical record filling 24 hours after service completion. Descriptive research method with a quantitative approach. The coding data is taken in the patient's medical record file, then the diagnosis code is confirmed with laboratory results notes in the medical record attachment. The data used were all medical record files for the period of January 2019. The number of samples in this study were 74 medical record files. The percentage of incompleteness in the identification of names was 30%, the percentage of incompleteness in the identification of the medical record number was 40%, the percentage of incompleteness in the identification of the age was 60%, the percentage of incompleteness in the identification of the signature was 10%, the percentage of incompleteness in the identification of the name of the person in charge was 10%, and the percentage of completeness in documentation that actually amounts to 100%. The incompleteness of filling in medical record files determines the accuracy of coding, assists in data analysis, is the basis for determining policies and produces quality data. The completeness of filling out medical record files is influenced by several factors including medical record officers, doctors and other officers who play a role in filling out medical record files.