Pengaruh Pelatihan Manajemen Rekam Medis Terhadap Kualitas Dokumentasi Medis di Pelayanan Kesehatan

Abstract

The quality of medical documentation is a crucial factor in healthcare services, playing a role in the continuity of patient care, clinical decision-making, and legal aspects. Proper medical record management can enhance the accuracy, completeness, and efficiency of patient data documentation. This study aims to analyze the impact of medical record management training on the quality of medical documentation in healthcare facilities. The research method used is a quantitative design with a cross-sectional approach. Data were collected through questionnaires and direct observations before and after training sessions for medical record officers in various hospitals and clinics. The results indicate that medical record management training significantly contributes to improving the completeness, timeliness, and compliance in patient data documentation. Therefore, regular training and the implementation of electronic record-keeping systems are recommended to enhance the quality of medical documentation.