Analysis of Completeness of Filling in Medical Records in Inpatients of Orthopedic Surgery to Improve Quality Services at Hasan Sadikin Hospital Bandung, Indonesia

This study aimed to find out how to implement filling out the medical records for orthopedic surgery at Hasan Sadikin General Hospital, Bandung. The research was conducted using a qualitative descriptive method, namely analyzing and describing the data and explaining the results obtained in full on the completeness of the medical record. The results showed that filling out the medical record form was incomplete with a population of 139 Delinquent Medical Record (DMR) samples; 54 DMR were taken. The highest incomplete form in the Authentication Review, namely "Nursing Assessment," there were 12(22%) complete 42(78%) incomplete; the highest incomplete form in the Reporting Review, namely "Medication Notes," there were 13(24%) complete 41(76%) incomplete. Incomplete medical record filling includes (1) The level of understanding of nurses and doctors on the importance of filling out medical records, (2) Doctors' delays and limitations on practice time, (3) Doctors and nurses' busyness levels, (4) Doctors' dependence on nurses, (5) the lack of attention of doctors and nurses towards filling out medical records. Suggestions for assembling officers to be more focused and pay attention to their work so that medical record documents with incomplete contents can be controlled and controlled periodically so that medical record documents are better with lower DMR numbers on filling