Analisis Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Rawat Inap di Rumah Sakit Umum Kaliwates Jember

Pratiwi, Azizah Nur (2026) Analisis Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Rawat Inap di Rumah Sakit Umum Kaliwates Jember. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Data from Kaliwates General Hospital Jember for the period of January-May 2025 the percentage of incomplete inpatient medical records ranged from 27.85% to 29.93%, this finding indicates that the completeness of inpatient medical records had not yet achieved the Minimum Service Standard (MSS) target of 100% medical record completeness. This study aimed to analyze the factors causing incomplete inpatient medical record documentation based on Lawrence Green’s behavioral theory, which includes predisposing, enabling, and reinforcing factors. This study employed a qualitative design. Data were collected through interviews, observation, documentation, and discussions. The research subjects consisted of two specialist doctors, three nurses, one ward supervisor, two medical record officers, and one head of the medical record unit. The results showed that the predisposing factor was limited staff knowledge regarding required documentation items and completion time standards stated in the Standard Operating Procedures (SOP). Enabling factors included incomplete understanding of SOPs, lack of SOP availability in inpatient wards, and suboptimal electronic medical record forms. The reinforcing factor indicated that no reward system had been implemented. Proposed improvements include on-the-job training, regular SOP dissemination, electronic system improvements, and providing rewards to improve documentation completeness.

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