Analisis Faktor Ketidaklengkapan Rekam Medis Pasien Rawat Inap di Ruang NICU RSUD Dr. TC Hilles Maumere

Baga, Yulfrita Serlyn (2025) Analisis Faktor Ketidaklengkapan Rekam Medis Pasien Rawat Inap di Ruang NICU RSUD Dr. TC Hilles Maumere. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Medical records are considered complete when they are 100% filled out by the Healthcare Professionals (PPA) within 24 hours after the patient is discharged. During the period from June to August 2023, out of 270 inpatient medical records in the NICU of RSUD Dr. TC Hillers Maumere, only 67 (25%) were complete, while 203 (75%) were incomplete. This study aims to analyze the factors contributing to the incompleteness of medical record documentation based on Robbins' performance theory, which includes motivation, opportunity, and ability. The study uses a qualitative method with interview, observation, and documentation techniques, as well as the USG method (Urgency, Seriousness, Growth) and brainstorming. The research findings indicate that the motivational factor contributing to incomplete medical records is the absence of rewards for staff who complete records thoroughly and the lack of written sanctions for those who do not. The opportunity-related factor is the unavailability of Standard Operating Procedures (SPO) for medical record documentation in the NICU, resulting in suboptimal socialization, monitoring, and evaluation processes. Additionally, the complexity of the forms is also a challenge. The ability-related factor is the lack of internal and external training on how to properly fill out medical records, as well as insufficient dissemination of information regarding the deadlines for completion. Based on the USG method analysis, the primary factor contributing to the incompleteness is the lack of available training, with the highest score of 134. It is recommended to implement both internal and external training programs to improve the completeness of medical record documentation.

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