Input–Process–Output Evaluation of Inpatient Medical Record Management at Beriman Regional General Hospital, Balikpapan

Inpatient medical record management is essential for continuity of care, administrative accountability, claim verification, legal protection, and hospital service quality. However, hospitals still face problems related to incomplete documents, delayed file returns, limited facilities, and the transition from manual to electronic medical record systems. Objective: This study aimed to evaluate inpatient medical record management based on the input, process, and output dimensions at Beriman Regional General Hospital, Balikpapan. Methodology: This study used a descriptive qualitative design. Data were collected through observation, in-depth interviews, and documentation involving five informants from the Medical Record Unit, consisting of the head of the medical record installation, data processing officer, filing officer, coding officer, and registration officer. Data were analyzed using qualitative descriptive analysis through data collection, data reduction, data display, and conclusion drawing. Findings: The results showed that the number of staff was relatively adequate; however, several personnel did not have an educational background in medical records and had not received structured training. The workflow generally followed standard operating procedures, including registration, file distribution, document completion, assembling, completeness analysis, coding, claim verification, and filing. Nevertheless, implementation was constrained by incomplete discharge summaries, blank informed consent forms, missing physician signatures, illegible handwriting, delayed file returns, limited infrastructure, and repeated file movement in the hybrid manual–electronic system. Document access was relatively easy through SIMRS and borrowing logbook procedures, but file completeness and neatness had not been fully achieved. Implication: The findings highlight the need to strengthen staff competence, regular training, infrastructure, SOP compliance, internal audits, and integrated electronic medical record implementation. Originality: This study provides an integrated input–process–output evaluation model for identifying root causes and improvement priorities in inpatient medical record management.