Article Per Year (5 Year)
p-Index From 2020 - 2025
1.745
P-Index
This Author published in this journals
All Journal Health Sciences and Pharmacy Journal Jurnal Bahana Kesehatan Masyarakat (Bahana of Journal Public Health) Bali Medika Jurnal Indonesian Journal of Global Health research Basic and Applied Nursing Research Journal JURNAL KESEHATAN SAMODRA ILMU Jurnal Akademika Baiturrahim Jambi
Adiputra, I Made Sudarma
Unknown Affiliation
Dentistry Education Environmental Science Health Professions Languange, Linguistic, Communication & Media Medicine & Pharmacology Nursing Public Health

Published : 13 Documents Claim Missing Document
Claim Missing Document
Check
Articles

Found 1 Documents
Search
Journal : Jurnal Akademika Baiturrahim Jambi

 1 
Tingkat Kelengkapan Rekam Medis di Puskesmas I Denpasar Timur : Pendekatan Kuantitatif Indraswari, Made Ayu Savitri; Adiputra, I Made Sudarma; Faidah, Nurul
Jurnal Akademika Baiturrahim Jambi Vol. 14 No. 2 (2025): September
Publisher : Universitas Baiturrahim

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.36565/jab.v14i2.958

Abstract

Medical records are essential documents that serve as a means of communication among healthcare professionals and form the basis for service planning, evaluation, and legal evidence within the healthcare system. The completeness of medical record documentation is a key indicator in ensuring the quality of healthcare services. This study aims to analyze the completeness level of outpatient medical records at UPTD Puskesmas I, East Denpasar District Health Office. A quantitative descriptive approach was used with random sampling techniques applied to 372 medical record files out of a total population of 5,251. Data collection was conducted using a checklist that assessed four main aspects: patient identification, essential reports, authentication, and proper documentation. The data were analyzed using univariate analysis. The results showed that the average completeness for patient identification was 67.3%, essential reports 95.38%, authentication 50%, and documentation 100%. Overall, the completeness of medical records has not fully met the established standards, particularly in legal and administrative aspects. This incompleteness may lead to serious consequences, such as errors in medical service delivery, weak legal accountability, and reduced quality of healthcare services. Therefore, this study highlights the need to strengthen internal supervision, conduct regular training for healthcare workers on proper medical record documentation, and implement routine evaluations to improve service quality and regulatory compliance
Co-Authors Aditya, Made Wahyu Arianta, I Made Dwi Damayanti, Putu Sri Gristiari, Ni Made Piar Indraswari, Made Ayu Savitri Komalasari, Ni Luh Putu Ratih Mitayanti, Ni Kadek Ni Luh Putu Devhy, Ni Luh Putu Ni Wayan Trisnadewi, Ni Wayan Nuralim, Ristu Airul Nurul Faidah Oktaviani, Ni Putu Wiwik Oktviani, Ni Putu Wiwik Parlin, Gusti Ayu Ketut Utari Pinatih, G. N. Indraguna Pradnyantara, I Gusti Agung Ngurah Putra Pramesti, Theresia Anita Urmilasari, Ni Putu Yessi Wahyudi, Hendro Widiastuti, Dewa Ayu Putri