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Abstract

A medical resume serves as a vital document that compiles essential information related to a patient’s clinical management. In 2019, the completeness rate of medical resume documentation at Pesawaran Regional General Hospital was only 37.4%. This study aimed to identify factors influencing the completeness of medical resume documentation by doctors through a quantitative, cross-sectional design involving 37 inpatient care doctors. Data were collected via questionnaires and direct observation, then analyzed using univariate, bivariate (Chi-Square), and multivariate (Logistic Regression) methods. Observation showed that 56.8% of medical resumes were incomplete. Questionnaire results indicated that 54.1% of respondents had negative perceptions of Standard Operating Procedures (SOP), 51.4% had high motivation, 62.2% perceived low rewards, 59.5% experienced democratic leadership, and 54.1% faced inadequate supervision. Bivariate analysis found significant associations between completeness and perceptions of SOP (p-value = 0.006; OR = 9.6), motivation (p-value = 0.029; OR = 6.0), leadership style (p-value = 0.044; OR = 5.8), and supervision (p-value = 0.001; OR = 18.4), while no significant association was found with perceived rewards (p-value = 0.760). Multivariate analysis identified supervision as the most dominant factor (OR = 39.281). These findings suggest that strengthening supervisory mechanisms and improving SOP clarity and implementation are essential for enhancing documentation completeness. Hospital management is advised to establish regular, structured supervision and continuous SOP review to ensure consistent compliance among doctors.

References

Alfiansyah, G. et al. (2023) ‘Faktor Penyebab Keterlambatan Pengembalian Rekam Medis Rawat Inap di Rumah Sakit’, Jenggala : Jurnal Riset Pengembangan dan Pelayanan Kesehatan, 2(1), pp. 54–63. Available at: https://jurnal.iik.ac.id/index.php/jenggala/article/view/88.

Apriyantini, D. (2016) ‘Analisis Hubungan Kelengkapan Pengisian Resume Medis Terhadap Kesesuaian Standar Tarif INA-CBG’s Instalasi Rawat Inap Teratai RSUP Fatmawati Jakarta’, Jurnal ARSI : Administrasi Rumah Sakit Indonesia, 2(3), pp. 194–203. Available at: https://doi.org/https://doi.org/10.7454/arsi.v2i3.2201.

Arabi, Y.M. et al. (2022) ‘Electronic medical record implementation in a large healthcare system from a leadership perspective’, BMC Medical Informatics and Decision Making, 22(1), p. 66. Available at: https://doi.org/10.1186/s12911-022-01801-0.

Armstrong, M. and Brown, D. (2023) Armstrong’s Handbook of Reward Management Practice: Improving Performance Through Reward. 7th edn. London: Kogan Page 2.

Badev, A. et al. (2025) Lessons on Supervisory Effectiveness – A Literature Review. Available at: https://www.bis.org/bcbs/publ/wp45.pdf.

Bakker, A.B. et al. (2023) ‘Daily transformational leadership: A source of inspiration for follower performance?’, European Management Journal, 41(5), pp. 700–708. Available at: https://doi.org/10.1016/j.emj.2022.04.004.

Bayisa, G. et al. (2024) ‘Improving medical record completeness at Wallaga University Referral Hospital: a multidimensional quality improvement project’, BMJ Open Quality, 13(1), p. e002665. Available at: https://doi.org/10.1136/bmjoq-2023-002665.

Decree of the Minister of Health Number 129/Menkes/SK/II/2008 on Hospital Minimum Service Standards (2008). Indonesia.

Demsash, A.W. et al. (2023) ‘Health professionals’ routine practice documentation and its associated factors in a resource-limited setting: a cross-sectional study’, BMJ Health & Care Informatics, 30(1), p. e100699. Available at: https://doi.org/10.1136/bmjhci-2022-100699.

Fischer, T. and Sitkin, S.B. (2023) ‘Leadership Styles: A Comprehensive Assessment and Way Forward’, Academy of Management Annals, 17(1). Available at: https://doi.org/https://doi.org/10.5465/annals.2020.0340.

Fitriani, A.D., Amirah, A. and Sitorus, M.S. (2022) ‘Analysis of the Relationship between Completeness of Completion of Medical Record Documents for Surgical Patients and Compliance with INA-CBG’s Tariff Standards’, International Journal Papier Advance and Scientific Review, 3(1), pp. 1–10. Available at: https://doi.org/10.47667/ijpasr.v3i1.137.

Grošelj, M. et al. (2021) ‘Authentic and transformational leadership and innovative work behaviour: the moderating role of psychological empowerment’, European Journal of Innovation Management, 24(3), pp. 677–706. Available at: https://doi.org/10.1108/EJIM-10-2019-0294.

Haqqi, A., Aini, N.N. and Wicaksono, A.P. (2020) ‘Analisis Faktor Penyebab Keterlambatan Pengembalian Berkas Rekam Medis Rawat Inap di RS Universitas Airlangga’, J-REMI: Jurnal Rekam Medis dan Informasi Kesehatan, 1(4), pp. 492–501. Available at: https://doi.org/https://doi.org/10.25047/j-remi.v1i4.2158.

Holmes, A.C., Acker, L.D. and Boettcher, M.L. (2021) ‘Supervision, leadership, and management: Distinct, yet complementary’, New Directions for Student Services, 2021(175), pp. 19–30. Available at: https://doi.org/10.1002/ss.20393.

Horgan, J. and Freundlich, L. (2024) Elevating Mission Impact: How Skilled Supervision Drives Organizational Success, TSNE (Partners in Social Change). Available at: https://tsne.org/better-nonprofit-management-series/elevating-mission-impact-how-skilled-supervision-drives-organizational-success/.

Husnun, F. (2017) Faktor-Faktor yang Berhubungan dengan Kelengkapan Pengisian Rekam Medis Pasien Rawat Inap oleh Dokter di RSUD Dr. Rasidin Padang Tahun 2016. Universitas Andalas. Available at: http://scholar.unand.ac.id/22713/.

Istirochah, Wajdi, M.F. and Syamsudin (2016) Analisis Kepatuhan Dokter Dalam Mengisi Rekam Medis di Rumah Sakit Umum Daerah Kabupaten Boyolali. Universitas Muhammadiyah Surakarta. Available at: https://eprints.ums.ac.id/48592/.

Kulkarni, S. (2023) ‘Role of Social Media in Shaping Consumer Perception’, International Journal of Applied Research, 9(10), pp. 183–190. Available at: https://www.allresearchjournal.com/archives/?year=2023&vol=9&issue=10&part=D&ArticleId=11324.

Lufianti, S.A. et al. (2022) ‘Analisis Faktor Penyebab Ketidaklengkapan Resume Medis Rawat Inap di Puskesmas Cermee Bondowoso’, Jurnal Rekam Medik & Manajemen Informasi Kesehatan, 1(2), pp. 80–86. Available at: https://doi.org/10.47134/rmik.v1i2.21.

Minister of Health Regulation Number 269/Menkes/Per/III/2008 on Medical Resume (2008). Indonesia.

Minister of Health Regulation Number 512/Menkes/Per/IV/2007 on Medical Practice Licences and the Practice of Medical Profession (2007). Indonesia.

Ministry of Health (2005) Pedoman Pengelolaan Rekam Medis Rumah Sakit di Indonesia Revisi I. Jakarta.

Nickerson, C. (2025) Herzberg’s Two-Factor Theory of Motivation-Hygiene, Simply Psychology. Available at: https://www.simplypsychology.org/herzbergs-two-factor-theory.html.

Notoatmodjo, S. (2012) Promosi Kesehatan dan Perilaku Kesehatan. Jakarta: Rineka Cipta.

Nurhaidah, Harijanto, T. and Djauhari, T. (2016) ‘Faktor-Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Rawat Inap di Rumah Sakit Universitas Muhammadiyah Malang’, Jurnal Kedokteran Brawijaya, 29(3), pp. 258–264. Available at: https://doi.org/https://doi.org/10.21776/ub.jkb.2016.029.03.4.

Nurrudin and Suprapto, S.I. (2022) ‘Analysis of Factors Affecting the Completeness of Medical Record Filling in Public Health Center Gayam’, Journal for Quality in Public Health, 5(2), pp. 408–416. Available at: https://doi.org/10.30994/jqph.v5i2.328.

Paulus, A.A., Dharmawan, Y. and Agushybana, F. (2019) ‘Faktor-Faktor yang Berhubungan dengan Kelengkapan Pengisian Rekam Medis di Rumah Sakit Tahun 2018. Semarang: Universitas Diponegoro’, Jurnal Kesehatan Masyarakat, 7(4), pp. 395–403. Available at: https://doi.org/https://doi.org/10.14710/jkm.v7i4.24810.

Pesawaran Regional General Hospital (2019) Laporan Tahunan RSUD Pesawaran Tahun 2019.

Pratiwi, M.A. et al. (2021) ‘Faktor Penyebab Ketidaklengkapan Pengisian Resume Medis Guna Penunjang Akreditasi di RS Bhayangkara Lumajang’, J-REMI: Jurnal Rekam Medis dan Informasi Kesehatan, 2(4), pp. 481–496. Available at: https://doi.org/https://doi.org/10.25047/j-remi.v2i4.2328.

Raoush, A. (2023) ‘Transformational leadership impact on innovative behaviour as perceived by healthcare workers in private hospitals in Jordan’, Cogent Business & Management, 10(3). Available at: https://doi.org/10.1080/23311975.2023.2265606.

Rose, M. (2022) Reward Management: A Practical Introduction. 3rd edn. London: Kogan Page.

Rosyada, A., Lazuardi, L. and Kusrini, K. (2017) ‘Persepsi Petugas Kesehatan Terhadap Peran Rekam Medis Elektronik Sebagai Pendukung Manajemen Pelayanan Pasien Di Rumah Sakit Panti Rapih’, Journal of Information Systems for Public Health, 2(1), pp. 1–10. Available at: https://doi.org/https://doi.org/10.22146/jisph.6659.

Shields, J. et al. (2020) Managing Employee Performance and Reward: Systems, Practices and Prospects. 3rd edn. Cambridge: Cambridge University Press.

Snowdon, D.A. et al. (2020) ‘Effective clinical supervision of allied health professionals: a mixed methods study’, BMC Health Services Research, 20(1), p. 2. Available at: https://doi.org/10.1186/s12913-019-4873-8.

Sundararajan, V. and Koh, H. (2020) ‘Exploring the relationship between motivation and the completeness of medical resumes: A cross-sectional study’, Journal of Medical Education, 44(3), pp. 352–359. Available at: https://doi.org/https://doi.org/10.1016/j.jmed.2020.01.005.

Taye, B.K. et al. (2023) ‘Data completeness and consistency in individual medical records of institutional births: retrospective crossectional study from Northwest Ethiopia, 2022’, BMC Health Services Research, 23(1), p. 1189. Available at: https://doi.org/10.1186/s12913-023-10127-0.

Theresia, V.S., Saptaningsih, A.B. and Hasyim, H. (2022) ‘The Influence of Motivation, Attitudes, and Knowledge on Doctors’ Compliance in Filling Out Medical Resumes’, Journal of Management Review, 6(3), pp. 815–821. Available at: https://doi.org/http://dx.doi.org/10.25157/mr.v6i3.7562.

Trianto, W. and Rohaeni, N. (2021) ‘Analisis Kepatuhan Pengisian Resume Medis Elektronik Rawat Inap KSM Kesehatan Anak Guna Menunjang Kualitas Rekam Medis di RSUP Dr. Hasan Sadikin Bandung’, Jurnal TEDC, 15(2), pp. 1–8. Available at: http://ejournal.poltektedc.ac.id/index.php/tedc/article/view/631.

Wijayanti, R. et al. (2024) ‘Analysis of Factors Causing Incomplete Filling of Medical Resumes at Pratama Clinic’, International Journal of Health and Information System, 2(1), pp. 57–66. Available at: https://doi.org/https://doi.org/10.47134/ijhis.v2i1.42.

Wirajaya, M.K.M. and Dewi, N.M.U.K. (2019) ‘Analisis Ketidaklengkapan Rekam Medis Pasien Rawat Inap di Rumah Sakit Dharma Kerti Tabanan’, Jurnal ARSI : Administrasi Rumah Sakit Indonesia, 6(1). Available at: https://doi.org/10.7454/arsi.v6i1.3553.

Wongso, E.S., Tahjoo, A. and Nofierni, N. (2024) ‘Competency, Motivation, and Supervision Technique Strong Predict to Completeness of Nursing Documentation’, International Journal of Nursing and Health Services (IJNHS), 7(5), pp. 164–172. Available at: https://doi.org/10.35654/ijnhs.v7i5.800.

Yulianita, H. et al. (2020) ‘Improving the quality of nursing documentation using supervision of the head of room’, EurAsian Journal of BioSciences Eurasia J Biosci, 14, pp. 7579–7584. Available at: http://www.ejobios.org/archive.html.

Bahasa Abstract

Resume medis merupakan dokumen penting yang memuat informasi esensial terkait penatalaksanaan klinis pasien. Pada tahun 2019, tingkat kelengkapan dokumentasi resume medis di Rumah Sakit Umum Daerah Pesawaran hanya mencapai 37,4%. Penelitian ini bertujuan untuk mengidentifikasi faktor-faktor yang memengaruhi kelengkapan dokumentasi resume medis oleh dokter melalui studi kuantitatif dengan desain potong lintang yang melibatkan 37 dokter rawat inap. Data dikumpulkan melalui kuesioner dan observasi langsung terhadap resume medis, kemudian dianalisis menggunakan metode univariat, bivariat (uji Chi-Square), dan multivariat (Regresi Logistik). Hasil observasi menunjukkan bahwa 56,8% resume medis tidak lengkap. Berdasarkan kuesioner, 54,1% responden memiliki persepsi negatif terhadap Standar Operasional Prosedur (SOP), 51,4% memiliki motivasi tinggi, 62,2% menilai rendahnya penghargaan, 59,5% mengidentifikasi gaya kepemimpinan demokratis, dan 54,1% mengalami pengawasan yang kurang memadai. Analisis bivariat menunjukkan adanya hubungan yang signifikan antara kelengkapan dokumentasi dengan persepsi terhadap SOP (p-value = 0,006; OR = 9,6), motivasi (p-value = 0,029; OR = 6,0), gaya kepemimpinan (p-value = 0,044; OR = 5,8), dan pengawasan (p-value = 0,001; OR = 18,4), sementara persepsi terhadap penghargaan tidak menunjukkan hubungan yang signifikan (p-value = 0,760). Analisis multivariat mengonfirmasi bahwa pengawasan merupakan faktor paling dominan (OR = 39,281). Temuan ini menunjukkan bahwa penguatan mekanisme pengawasan serta peningkatan kejelasan dan penerapan SOP merupakan langkah krusial untuk meningkatkan kelengkapan dokumentasi resume medis. Manajemen rumah sakit disarankan untuk menerapkan pengawasan yang terstruktur dan rutin serta melakukan evaluasi SOP secara berkala guna memastikan kepatuhan dokumentasi oleh dokter.

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