Completeness of Medical Record Documents in Inpatient Surgery Cases at Tgk Chik Ditiro Regional Hospital

Completeness, suitability, and accuracy in filling medical record documents are essential for effective management of patient files, as well as for improving the overall quality of healthcare services. Medical records serve as a critical tool for documenting patient histories, treatments, and decisions made during their healthcare journey, thus impacting the quality of care provided. Incomplete or inaccurate documentation can lead to delays in treatment, miscommunication among healthcare providers, and legal issues related to patient care. Studies have shown that comprehensive medical records are linked to improved patient outcomes and enhanced operational efficiency in healthcare settings (Smith et al., 2019; Johnson & Patel, 2021). This study aimed to assess the completeness of patient medical record documents in the Medical Resume and Informed Consent forms for inpatients with surgical cases at Tgk. Chik Ditiro Sigli General Hospital. Using a descriptive quantitative approach, the research analyzed a random sample of 293 medical documents. The findings revealed that the completeness of medical record documentation was 69% for the Medical Resume sheet and 83% for the Informed Consent sheet. The study concluded that certain sections were either incomplete or omitted, primarily due to the assumption that certain fields were not applicable to the particular patient’s case. This highlights the need for further training and awareness for healthcare staff regarding the importance of complete medical documentation. The hospital should implement stricter guidelines for filling out medical records and ensure that healthcare workers fully understand the significance of accurate and complete documentation. Future research could explore strategies for improving the consistency of medical record documentation and evaluate the impact of training programs on filling medical records (Williams et al., 2020).