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Abstract

Background: Medical records / patient medical records are an important part in helping the implementation of health services to patients in the hospital. Based on Permenkes No. regulation 269 / Menkes / Per / III / 2008, a medical record is a file that contains records and documents about the patient's identity, examination, treatment measures and other services that have been provided to the patient. The research objective is to identify the completeness of filling medical records in the outpatient unit of RSIA Bunda Aliyah, in the context of efforts to improve health services in hospitals, medical records can also be used as evidence of disease progression, care that has been given and as a means of communication between Health workers. Method: quantitative research by taking a sample (purposive sampling) as many as 328 medical records were taken at BIA Aliyah Hospital. Results: obtained complete outpatient medical record components complete as a whole (94%) while the incompletely filled (6%) file. From the completeness of outpatient medical record data, there are the top 3 that are not completely filled, including the names of doctors as many as 97 files, as much as 63 files of management recommendations, and the number of participants / cards as many as 54 files.

References

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