Identifikasi Hubungan Kelengkapan Berkas Rekam Medis Pasien Kontrol Pasca Rawat Inap

Abstract

The completeness of medical records is a crucial aspect of healthcare services, serving as a source of patient information for continued care, evaluation, and clinical decision-making. Patients undergoing post-hospitalization follow-up require complete medical records to ensure continuity of service and quality of care. This study aims to identify the relationship between the completeness of medical records and the quality of care for post-hospitalization follow-up patients.

The research employs a cross-sectional design with a quantitative approach. Data were collected through medical record audits and interviews with healthcare professionals at the hospital. The findings indicate that the completeness of medical records has a significant relationship with the accuracy of subsequent diagnoses and the effectiveness of treatment for post-hospitalization follow-up patients. Therefore, efforts to improve medical record management are necessary through healthcare staff training and the implementation of a more efficient health information system.