<![CDATA[Outpatient medical record information management at the Catya Husada Pratama Clinic, Bravo 90 Detachment, Kopasgat is currently conducted manually using Microsoft Excel with copy-paste techniques. This condition leads to incomplete data, inaccuracies, and delayed completion of completeness reports due to inefficient workflows. This study aims to design and implement an information system to improve the completeness of outpatient medical record keeping to optimize clinical documentation. The research method applied is qualitative, utilizing data collection techniques through observation, interviews, and literature reviews. System development was carried out gradually and systematically using the Waterfall method. The results identified several key issues: suboptimal completeness of medical record keeping, inaccuracy and untimeliness of manual recording, and delays in returning medical record files. As a solution, a system was designed using flowmaps, context diagrams, DFDs, ERDs, and database specifications via Microsoft Access, consisting of 5 tables (officer, patient, doctor, polyclinic, and completeness). The system was implemented using Visual Basic.Net, which includes a Main Menu, Login Menu, Master Data Forms (Patient, Doctor, Polyclinic, Officer), a Completeness Analysis Form, and a Report Printing Form. System testing demonstrates that this application successfully presents analysis reports, completeness certificates, and visual graphs of analysis results. The author suggests the comprehensive implementation of this digital system to replace manual processes. The outcome of this research is an integrated system that accelerates report generation, minimizes data entry errors, and ensures the accuracy and integrity of clinical patient documentation.]]>
