The Incompleteness of Medical Record Documents: Causative Factor and Solution Studied on Private Hospital in Malang City

Quality services at hospitals are not only medical services but also support services. One of the parameters that can be used is data or information from a good and complete medical record. MRD filling in RS X has not reached 100 %. The percentage of completeness of MRD filling (Medical Record Document) by DPJP (Responsible Physician Service) is better than nurse, that is equal to 60-75 %, and the percentage of completeness of MRD filling by nurse reaches 35-50 %. This research, which aims to determine the factors causing incomplete filling of medical record, uses descriptive method. Data were taken during September-October 2017 through document review, field observation, interviews, and questionnaires. Factors that affect the incompleteness of the MRD filling are largely due to the human resources, that are different comprehension and incompleted MRD filling also lack of communication between MR officers with DPJP. Besides, it is also influenced by the process factor that is unavailability of SPO filling MRD, and there are still less systematic and repetitive forms materially. Some alternative solutions are review of medical record installation service guidance such as preparation of required SPO, gradual socialization, and monitoring implementation in the form of assistance in filling MRD by head of room. Alternative solutions are done under the coordination of the head of the RS Installation and some related PPA.