Determinants Of Complete Medical Records Of Inpatients In Hospital Level II Putri Hijau Kesdam I / BB Medan In 2018

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Introduction

Patient medical records play a crucial role in the healthcare system, as they contain vital information about a patient's medical history, diagnosis, treatment, and progress. However, the completeness of medical records is often a concern in many hospitals, including the Putri Hijau Level II Hospital located in Medan Kesdam I/BB. A study conducted in 2018 revealed that 80% of medical record files were not completely filled, raising concerns about the quality of healthcare services provided to patients. This article aims to discuss the determinants of complete medical records of inpatient patients in Hospital Level II Putri Hijau Kesdam I/BB Medan in 2018.

Background

The Putri Hijau Level II Hospital is a healthcare facility that provides medical services to patients in Medan Kesdam I/BB. The hospital has a team of specialist doctors, nurses, and other healthcare workers who work together to provide quality healthcare services. However, the study found that the completeness of medical records was a significant concern, with 80% of medical record files not being completely filled. The initial suspicion of the cause was the low commitment of specialist doctors and the ineffectiveness of communication between doctors and other health workers in the hospital.

Methodology

This study employed an Explanatory Research approach to analyze the determinants of complete medical records of inpatient patients in Hospital Level II Putri Hijau Kesdam I/BB Medan in 2018. The research population consisted of 50 specialist doctors, with a sample of 34 people used for the study. Data collection was carried out by distributing questionnaires, and analysis was conducted using multiple linear regression tests.

Results

The results of the study showed that the majority of workloads were in the mild category (32.4%), while the proportion of doctors who were not committed was quite high (29.4%). On the other hand, interpersonal communication touched good numbers (20.6%), but the completeness of medical records was still not good (55.9%). The analysis results also showed that the workload variable (p = 0.007), commitment (p = 0.013), and interpersonal communication (p = 0.033) had a significant effect on the completeness of medical records.

Discussion

The results of the study suggest that the workload, commitment, and interpersonal communication of specialist doctors have a significant effect on the completeness of medical records. When the workload increases, or when there is a low commitment and ineffective communication, the completeness of medical records can be affected. Among these three factors, workload is a dominant factor that affects the completeness of medical records.

Conclusion

The conclusion of this study confirms that there is a positive influence of the three factors (workload, commitment, and interpersonal communication) on the completeness of medical records. Therefore, it is advisable to hospital management to optimize the performance of nurses in reminding specialist doctors about the importance of filling a complete medical record. In addition, periodic evaluations of the completeness of medical records should be carried out, and a series of workshops on effective communication can be applied. Efforts to enforce discipline are also needed, such as imposing sanctions in the form of reprimands or periodic salary delays for specialist doctors who do not meet the obligation to fill medical records within three consecutive months.

Recommendations

Based on the findings of this study, the following recommendations are made:

  • Optimize the performance of nurses: Hospital management should optimize the performance of nurses in reminding specialist doctors about the importance of filling a complete medical record.
  • Periodic evaluations: Periodic evaluations of the completeness of medical records should be carried out to ensure that the quality of medical records is maintained.
  • Workshops on effective communication: A series of workshops on effective communication can be applied to improve the communication between doctors and other health workers in the hospital.
  • Enforce discipline: Efforts to enforce discipline are needed, such as imposing sanctions in the form of reprimands or periodic salary delays for specialist doctors who do not meet the obligation to fill medical records within three consecutive months.

Limitations

This study has several limitations, including:

  • Sample size: The sample size of 34 specialist doctors may not be representative of the entire population of specialist doctors in the hospital.
  • Data collection method: The data collection method used in this study was based on questionnaires, which may not be the most effective method for collecting data on the completeness of medical records.
  • Analysis method: The analysis method used in this study was based on multiple linear regression tests, which may not be the most appropriate method for analyzing the data.

Future Research Directions

Future research directions include:

  • Investigating the impact of workload on the completeness of medical records: Further research is needed to investigate the impact of workload on the completeness of medical records.
  • Examining the effect of commitment on the completeness of medical records: Further research is needed to examine the effect of commitment on the completeness of medical records.
  • Analyzing the impact of interpersonal communication on the completeness of medical records: Further research is needed to analyze the impact of interpersonal communication on the completeness of medical records.

Conclusion

In conclusion, this study found that the workload, commitment, and interpersonal communication of specialist doctors have a significant effect on the completeness of medical records. The results of this study suggest that hospital management should optimize the performance of nurses, carry out periodic evaluations of the completeness of medical records, and apply a series of workshops on effective communication. Efforts to enforce discipline are also needed, such as imposing sanctions in the form of reprimands or periodic salary delays for specialist doctors who do not meet the obligation to fill medical records within three consecutive months.

Q: What is the main objective of this study?

A: The main objective of this study is to analyze the determinants of complete medical records of inpatient patients in Hospital Level II Putri Hijau Kesdam I/BB Medan in 2018.

Q: What is the significance of this study?

A: This study is significant because it highlights the importance of complete medical records in ensuring the quality of healthcare services provided to patients. The study also identifies the determinants of complete medical records, which can inform hospital management and healthcare professionals on how to improve the completeness of medical records.

Q: What are the determinants of complete medical records identified in this study?

A: The determinants of complete medical records identified in this study are workload, commitment, and interpersonal communication.

Q: How does workload affect the completeness of medical records?

A: The study found that when the workload increases, the completeness of medical records can be affected. This is because specialist doctors may not have enough time to fill in all the necessary information in the medical record.

Q: How does commitment affect the completeness of medical records?

A: The study found that when specialist doctors are not committed to filling in medical records, the completeness of medical records can be affected. This is because specialist doctors may not see the importance of filling in medical records or may not have the necessary skills to do so.

Q: How does interpersonal communication affect the completeness of medical records?

A: The study found that when there is ineffective communication between doctors and other health workers in the hospital, the completeness of medical records can be affected. This is because specialist doctors may not receive the necessary information or support to fill in medical records.

Q: What are the recommendations of this study?

A: The recommendations of this study include optimizing the performance of nurses in reminding specialist doctors about the importance of filling a complete medical record, carrying out periodic evaluations of the completeness of medical records, and applying a series of workshops on effective communication. Efforts to enforce discipline are also needed, such as imposing sanctions in the form of reprimands or periodic salary delays for specialist doctors who do not meet the obligation to fill medical records within three consecutive months.

Q: What are the limitations of this study?

A: The limitations of this study include the sample size, data collection method, and analysis method. The sample size of 34 specialist doctors may not be representative of the entire population of specialist doctors in the hospital. The data collection method used in this study was based on questionnaires, which may not be the most effective method for collecting data on the completeness of medical records. The analysis method used in this study was based on multiple linear regression tests, which may not be the most appropriate method for analyzing the data.

Q: What are the future research directions of this study?

A: The future research directions of this study include investigating the impact of workload on the completeness of medical records, examining the effect of commitment on the completeness of medical records, and analyzing the impact of interpersonal communication on the completeness of medical records.

Q: What are the implications of this study for hospital management and healthcare professionals?

A: The implications of this study for hospital management and healthcare professionals are that they should prioritize the completeness of medical records and take steps to improve the quality of medical records. This can be achieved by optimizing the performance of nurses, carrying out periodic evaluations of the completeness of medical records, and applying a series of workshops on effective communication. Efforts to enforce discipline are also needed, such as imposing sanctions in the form of reprimands or periodic salary delays for specialist doctors who do not meet the obligation to fill medical records within three consecutive months.