Analysis of the Completeness of Surgical Patient Operation Report Filling to Support the Quality of Medical Records at Dr. Soedirman Regional General Hospital Kebumen

Abstract

Surgical reports are essential to ensuring the quality of medical procedures, facilitating healthcare insurance reimbursements, and serving legal purposes in court. These reports must be 100% complete following the Minimum Service Standards for medical records. This study assesses the completeness of neurosurgical patient operative reports at Hospital X in Bandung.This study employs a descriptive quantitative research design. The study population comprises 600 neurosurgical patient medical records from January to June 2024. Using the Slovin formula, a sample of 86 medical records was obtained. Data collection was conducted using an observation checklist table. The findings indicate that the completeness of neurosurgical patient operative reports is as follows: patient identification section at 99.5%, essential report section at 96.3%, authentication section at 99.67%, and proper documentation section at 93.67%. Based on interviews, the factors contributing to incomplete operative reports include the absence of a Standard Operating Procedure (SOP) for filling out reports, lack of accuracy from doctors or nurses in completing the reports, and the suboptimal use of electronic medical records in supporting electronic operative report documentation. The completeness of operative reports at Hospital X Bandung can be considered satisfactory but remains suboptimal, as the completeness percentage has not yet reached 100%.