PROSIDING INTERNASIONAL KEPERAWATAN Proceedings of the International Conference on Nursing and Health Sciences, Volume 3 No 1, May 2022.
COMPLETENESS OF MEDICAL RECORD DOCUMENTS FOR INPATIENT KIDNEY FAILURE AT THE HOSPITAL
Dublin Core
Title
PROSIDING INTERNASIONAL KEPERAWATAN Proceedings of the International Conference on Nursing and Health Sciences, Volume 3 No 1, May 2022.
COMPLETENESS OF MEDICAL RECORD DOCUMENTS FOR INPATIENT KIDNEY FAILURE AT THE HOSPITAL
COMPLETENESS OF MEDICAL RECORD DOCUMENTS FOR INPATIENT KIDNEY FAILURE AT THE HOSPITAL
Subject
analysis quantitative kidney failure; completeness of inpatient; medical record documents
Description
Health service providers are required to record all services provided to patients in the form of a complete
medical record file. Incomplete filling of medical records can lead to misinformation used by health
professionals in providing services or treatment plans. This study aims to determine the completeness of
medical record documents and the factors that cause incomplete medical record documents for kidney
failure.This research is a literature study. The sample in this study were 5 journals related to the
completeness of medical record documents for inpatient cases of kidney failure using purposive sampling
technique. The instrument in this study used the google application. Processing of data by searching on the
site, collecting overall journals, journal screening and extracting data based on inclusion criteria using the
Systematic Literature Review (SLR) method. The analysis was carried out using data analysis techniques,
namely quantitatively. The results of the study on the completeness of medical record documents for
inpatient kidney failure based on a review of patient identification, the entire journal was incomplete, 100%
incomplete, mostly on the name and age items. Review reporting there is 1 journal is 100% complete, 4
journals are not complete 100% incomplete mostly on date and time items, authentication review the entire
journal is not complete. 100% of the incompleteness is found in the items of the doctor's name and the
doctor's signature. The review of the recording of the entire journal is not complete. 100% of the
incompleteness is on the item using the fixed line on the blank form. The factor of the incompleteness of
the medical resume on the inpatient document is due to the lack of accuracy of the officers infilling, lack of
discipline of officers, and the absence of a clear SOP. The conclusion of this study is that from 5 journals
regarding the completeness of medical record documents in terms of reviews of identification, reporting,
authentication and recording, it shows that medical record documents are 100% incomplete. This is due to
the lack of accuracy of officers in filling it out, lack of discipline of officers, and the absence of clear SOPs.
medical record file. Incomplete filling of medical records can lead to misinformation used by health
professionals in providing services or treatment plans. This study aims to determine the completeness of
medical record documents and the factors that cause incomplete medical record documents for kidney
failure.This research is a literature study. The sample in this study were 5 journals related to the
completeness of medical record documents for inpatient cases of kidney failure using purposive sampling
technique. The instrument in this study used the google application. Processing of data by searching on the
site, collecting overall journals, journal screening and extracting data based on inclusion criteria using the
Systematic Literature Review (SLR) method. The analysis was carried out using data analysis techniques,
namely quantitatively. The results of the study on the completeness of medical record documents for
inpatient kidney failure based on a review of patient identification, the entire journal was incomplete, 100%
incomplete, mostly on the name and age items. Review reporting there is 1 journal is 100% complete, 4
journals are not complete 100% incomplete mostly on date and time items, authentication review the entire
journal is not complete. 100% of the incompleteness is found in the items of the doctor's name and the
doctor's signature. The review of the recording of the entire journal is not complete. 100% of the
incompleteness is on the item using the fixed line on the blank form. The factor of the incompleteness of
the medical resume on the inpatient document is due to the lack of accuracy of the officers infilling, lack of
discipline of officers, and the absence of a clear SOP. The conclusion of this study is that from 5 journals
regarding the completeness of medical record documents in terms of reviews of identification, reporting,
authentication and recording, it shows that medical record documents are 100% incomplete. This is due to
the lack of accuracy of officers in filling it out, lack of discipline of officers, and the absence of clear SOPs.
Creator
Tasya Aisyah Adinda Raekha, Sri Wahyuningsih, Nor Akmar Bt Mohd Yahya
Source
http://jurnal.globalhealthsciencegroup.com/index.php/PICNHS
Publisher
Global Health Science Group
Date
1, May 2022,
Contributor
peri irawan
Format
pdf
Language
english
Type
text
Files
Citation
Tasya Aisyah Adinda Raekha, Sri Wahyuningsih, Nor Akmar Bt Mohd Yahya, “PROSIDING INTERNASIONAL KEPERAWATAN Proceedings of the International Conference on Nursing and Health Sciences, Volume 3 No 1, May 2022.
COMPLETENESS OF MEDICAL RECORD DOCUMENTS FOR INPATIENT KIDNEY FAILURE AT THE HOSPITAL,” Repository Horizon University Indonesia, accessed April 30, 2025, https://repository.horizon.ac.id/items/show/2855.
COMPLETENESS OF MEDICAL RECORD DOCUMENTS FOR INPATIENT KIDNEY FAILURE AT THE HOSPITAL,” Repository Horizon University Indonesia, accessed April 30, 2025, https://repository.horizon.ac.id/items/show/2855.