Assessment of Medical Record Document Completeness in Inpatient Units Before and After STARKES Accreditation in a Private Hospital

DOI

10.2991/978-2-38476-132-6_4How to use a DOI?

Keywords

Medical Record Completeness; Hospital Minimum Service Standard; Medical Record Management

Abstract

The Hospital Minimum Service Standards include several key components, one of which is the vital management of medical records. Achieving 100% completeness in medical record documentation is a key indicator of success in the health sector, and it significantly influences the level of hospital accreditation. Therefore, this research aims to assess the completeness of medical record documents in inpatient units based on three essential forms, including Entry and Exit Summary, Clinical Notes, and Informed Consent. This assessment was carried out both before and after STARKES accreditation in a private hospital. The data used in this research include the complete recapitulation of medical record documents during two distinct periods, which were from October to December 2022 (before) and February to April 2023 (after accreditation). To achieve the aforementioned objective, a qualitative research methodology was employed, utilizing a descriptive method. Furthermore, the data collection process entailed the calculation of average data as well as conducting interviews to gain comprehensive insights. The data was meticulously processed using specialized software to determine the proportion of completeness and identify any differences before and after the accreditation. After analyzing the research data, the obtained results showed that the completeness of the three forms, both before and after STARKES accreditation, fell short of the prescribed standards. Strikingly the Paired Sample T-Test indicated that there was no statistically significant difference in the completeness of inpatient medical records during the two phenomena. As a result, it is imperative to emphasize the need for regular monitoring and evaluation of standard achievement, as well as the implementation of effective motivational strategies for officers responsible for ensuring the completeness of medical record documents.

Copyright

© 2023 The Author(s)

Open Access

Open Access This chapter is licensed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), which permits any noncommercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

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TY  - CONF
AU  - Badra Al Aufa
AU  - Eka Nuryanti
AU  - Susilawati
PY  - 2023
DA  - 2023/10/31
TI  - Assessment of Medical Record Document Completeness in Inpatient Units Before and After STARKES Accreditation in a Private Hospital
BT  - Proceedings of the 6th International Conference on Vocational Education Applied Science and Technology (ICVEAST 2023)
PB  - Atlantis Press
SP  - 19
EP  - 29
SN  - 2352-5398
UR  - https://doi.org/10.2991/978-2-38476-132-6_4
DO  - 10.2991/978-2-38476-132-6_4
ID  - Aufa2023
ER  -