Analisis Kelengkapan Formulir Asesmen Awal Medis IGD Guna Menunjang Mutu Rekam Medis Di RSUD Dr. Soedirman Kebumen

Abstract

This study aims to analyze the completeness of filling out initial medical assessment forms in the Emergency Department (ED) of RSUD Dr. Soedirman Kebumen as an indicator of medical record quality. Complete documentation in medical records is crucial for ensuring data accuracy, patient safety, and supporting precise and efficient clinical decision-making. A descriptive quantitative method was used with a sample of 50 forms out of 98 ED patient records from September to November 2024, selected randomly using the Slovin formula. The analysis showed that 82% of the forms were completed properly, while 18% did not meet the standards. October recorded the highest completion rate (87.5%), while November had the lowest (76.5%). The main contributing factors to incompleteness were human error, heavy workloads, time constraints, and suboptimal internal monitoring. This study recommends regular training, clear technical guidelines, consistent internal supervision, and consideration of implementing Electronic Medical Records (EMR) systems to improve documentation quality. Additionally, building a work culture that emphasizes the importance of medical documentation and applying a reward and punishment system is also essential. Through these integrated efforts, the quality of medical services is expected to improve, enabling the hospital to meet accountability standards and ensure optimal and sustainable patient care.