Qualitative Analysis of the Completeness of Medical Resume Documentation at Dr. Harjono S Regional Public Hospital, Ponorogo Regency

Arfi Prima Kusuma; Ani Rosita

doi:10.62027/vitamedica.v3i4.824

Authors

Arfi Prima Kusuma STIKES Buana Husada Ponorogo
Ani Rosita STIKES Buana Husada Ponorogo

DOI:

https://doi.org/10.62027/vitamedica.v3i4.824

Keywords:

Documentation Completeness, Electronic Records, Medical Resume, Quality Control, Staff Supervision.

Abstract

A medical resume is a summary of patient care that plays an essential role in administrative, clinical, legal, and hospital accreditation processes. It supports service quality and serves as legal medical evidence. This study aimed to analyze the completeness of medical resume documentation at Dr. Harjono S Regional Public Hospital, Ponorogo Regency, and identify factors contributing to incomplete documentation. The research used a qualitative descriptive method with a cross-sectional approach. Data were collected through observation of 15 inpatient medical resume documents from the Pediatrics and Orthopedics departments and interviews with medical record officers. The research instrument was an observation checklist covering seven documentation components. The results showed that supporting examination results had the highest completeness rate at 100%, while patient identity data had the lowest completeness rate at 67%. Factors contributing to incomplete documentation included a high workload, limited supervision, and low staff awareness regarding the importance of complete medical records. The absence of an internal quality control system was also identified as a major challenge. This study recommends strengthening staff training, conducting regular supervision, implementing internal quality control, and adopting electronic medical record systems to improve documentation completeness, accuracy, and overall service quality at the hospital for all patients.

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