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Factors Associated with the Completeness of Inpatient Medical Record Filling in Dr. R Sosodoro Djatikoesoemo, Bojonegoro, East Java

Tegar Wahyu Yudha Pratama, Didik Tamtomo, Endang Sutisna Sulaeman

Abstract

Background: Medical records are central to all patient healthcare activities. Fundamentally, they form part of a doctor’s ethical and statutory duty in providing good patient care.Good quality medical records, including completeness of record filling, are essential to proper ongoing care of the patient and are paramount for effective communication between healthcare professionals and their patients. However, studies in Indonesia examining factors associated with the completeness of inpatient medical record filling is scanty. The purpose of this study was to examine factors associated with the completeness of inpatient medical record filling in a district hospital.

Subjects and Method: This was a quantitative study using a cross-sectional design, conducted atDr. R. SosodoroDjatikoesomoBojonegoro hospital, East Java, in April 2018. A total of 213 nurses working at the inpatient service ward was selected for this study by proportional random sampling, composing of 115 nurses with graduate degree and 35 nurses with diploma degree. The dependent variable was completeness of inpatient medical record filling. The independent variables were education level, employment status, tenure, responsibility, and organization support. The data were collected by questionnaire and document review. The data were analyzed by a multiple logistic regression.

Results: Completeness of inpatient medical record fillingwas positively associated with higher education (OR= 2.94; CI 95%= 1.08 to 8.00; p=0.034), civil servant status of employment (OR= 4.01; CI 95%= 1.71 to 9.40; p=0.001), ≥3 year tenure (OR= 8.84; CI 95%= 2.78 to 28.16; p<0.001), higher knowledge (OR= 5.37; CI 95%= 1.40 to 20.55; p=0.014), stronger responsibility (OR= 3.13; CI 95%= 1.35 to 7.28; p=0.008), and stronger organizational support (OR= 4.08; CI 95%= 1.72 to 9.67; p=0.001).

Conclusion: Completeness of inpatient medical record fillingis positively associated with higher education, civil servant status of employment, ≥3 year tenure, higher knowledge, stronger responsibility, and stronger organizational support.

Keywords: completeness, inpatient, medical record, filling

Correspondence: Tegar Wahyu Yudha Pratama. School of Medical Records and Health, STIKES Muhammadiyah, Bojonegoro. Email: tegar.wahyu404@gmail.com. Mobile: +6285746085030.

Journal of Health Policy and Management (2018), 3(1): 1-10
https://doi.org/10.26911/thejhpm.2018.03.01.01

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