Analysis of the Completeness of Electronic Medical Record Documents on the Operation Report Form in the Bougenville Room Based on the Minimum Service Standards for Hospitals at Rsud Cibinong in 2025

Abstract

Electronic Medical Records (EMR) play a crucial role in ensuring the quality of hospital services. One of the essential components of the EMR is the operative report form, which must be completed accurately and within 24 hours after surgery in accordance with the hospital’s Minimum Service Standards (MSS). Delays or incomplete documentation may impact service quality and pose legal risks. This study aims to analyze the completeness and timeliness of operative report form entries in the EMR system at Bougenville Ward, Cibinong Regional Hospital in 2025, and to identify factors contributing to delays in documentation. This study employs a descriptive qualitative approach using Miles and Huberman’s data analysis model, which includes data reduction, data display, and conclusion drawing. A total of 303 operative report forms were reviewed for completeness and timeliness, and contributing factors were analyzed using a Fishbone Diagram framework. Of the 303 operative report forms analyzed, 280 forms (92.4%) were completed on time and in full, while 23 forms (7.6%) were filled out late, although still complete in content. No incomplete forms were found. Contributing factors to delays include human resources (heavy workload, lack of discipline), methods (absence of reminders or enforcement in SOPs), technical issues with the EMR system, as well as managerial and environmental conditions. Delays in completing operative report forms stem from interrelated systemic issues involving personnel, procedures, and technology. Solutions should include strengthening SOPs, developing automated reminders within the EMR system, regular staff training, and upgrading technological infrastructure to support compliance with hospital MSS.