Analisis Faktor Penyebab Ketidaklengkapan Rekam Medis Rawat Inap Di Puskesmas Andongsari Kabupaten Jember

Chandrasya, Imania (2026) Analisis Faktor Penyebab Ketidaklengkapan Rekam Medis Rawat Inap Di Puskesmas Andongsari Kabupaten Jember. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

The incompleteness of inpatient medical record documentation remains a problem that may affect the quality of healthcare services, legal and administrative aspects, and the continuity of patient care. Based on a survey conducted at Andongsari Public Health Center, Jember Regency, during the January–June 2025 period, the incompleteness rate of inpatient medical records reached 84.1%. This study aimed to analyze the factors causing the incompleteness of inpatient medical records based on Lawrence Green's Behavioral Theory, determine the priority problems using the Urgency, Seriousness, and Growth (USG) method, and formulate alternative solutions through Brainstorming. This study employed a descriptive qualitative method. The research subjects consisted of seven informants, including the head of the public health center, one physician, one inpatient ward coordinator, three inpatient nurses, and one registration and medical records coordinator. The analysis was conducted based on predisposing factors, enabling factors, and reinforcing factors. The results showed that the predisposing factors included healthcare workers' lack of knowledge regarding the standard time for completing medical records, low discipline and responsibility, and educational background. The enabling factors included the unavailability of the Medical Record Incompleteness Checklist (KLPCM), the absence of a request form for incomplete medical record documentation, and the lack of training related to medical record completion. The reinforcing factors consisted of non-specific standard operating procedures (SOPs), insufficient dissemination of SOPs, and the absence of a reward and punishment system. Based on the USG analysis, the main priority problems were the low level of discipline and responsibility among healthcare workers and the lack of supporting facilities for ensuring the completeness of medical records. The recommended efforts include strengthening monitoring and evaluation activities, conducting regular training and SOP dissemination, implementing a reward and punishment system, and providing KLPCM forms and request forms for incomplete medical record documentation.

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