ANALYSIS OF OUTPATIENT’S MEDICAL RECORDS COMPLETENESS AT THE SUNGAI SIRING HEALTH CENTER IN SAMARINDA

Abstract

A medical record is a document that contains information about the patient, disease, treatment and further action to be given to the patient following the order of service. At the puskesmas, several medical records were found that were not filled in completely. This is due to several factors, namely human resources, Facilities and Infrastructure, methods, materials and finance. This study aims to analyze the completeness of medical records for outpatients at Sungai Siring Samarinda Health Center. The research design is qualitative using the Delphi method. This research was conducted at the Sungai Siring Samarinda Health Center with 5 informants namely Doctors, Nurses, Midwives, Medical Record Officers and Heads of the Puskesmas. Data was collected by way of FGD (Focus Group Discussion) and document review. The results of the study from the human resource factor were the problem of incomplete medical records because nurses, midwives and medical record officers saw many patients, so officers were in a hurry to fill out documents so some medical records were incomplete. The equipment factor is the unavailability of the assembly room which makes the officers unable to always check the completeness of the medical records. The method factor, there is no fixed policy related to SOP for filling in medical records and also outreach related to SOP. In addition, each officer does not get rewards and punishments. Material factors, namely sometimes the medical record form is lost and the form to be used is also full. The financial factor, the funds needed are not fully there because there are many other more important needs. Incomplete medical records for outpatients at the Sungai Siring Health Center were influenced by several factors, namely human resource factors, equipment factors, method factors, material factors and financial factors. It is hoped that the Puskesmas can carry out outpatient medical records following the SOPs and existing regulations so that the implementation of medical records can run well in the future.