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All Journal Jurnal Peduli Masyarakat Jurnal Promotif Preventif Jurnal Kesehatan Tambusai Jurnal Keperawatan Florence Nightingale Jurnal Media Informatika Proceedings of the International Conference on Nursing and Health Sciences PubHealth Jurnal Kesehatan Masyarakat SENAPAS Inovasi Jurnal Pengabdian Masyarakat (IJPM) Prosiding Seminar Hasil Penelitian dan Pengabdian Kepada Masyarakat Karya Kesehatan Siwalima Jurnal Kesehatan Masyarakat Perkotaan Lontara Journal Of Health Science And Technology Jurnal Pengabdian Kesehatan
Arjuna Ginting, Arjuna
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Agriculture, Biological Sciences & Forestry Humanities Chemistry Computer Science & IT Dentistry Economics, Econometrics & Finance Education Engineering Environmental Science Health Professions Industrial & Manufacturing Engineering Languange, Linguistic, Communication & Media Mechanical Engineering Medicine & Pharmacology Nursing Public Health Social Sciences Other

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Journal : Karya Kesehatan Siwalima

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An Overview of Electronic Medical Record Completeness in the Management of Fracture Patients Ginting, Arjuna; Boris, Jey; Pasaribu, Angelia
Karya Kesehatan Siwalima Vol 4, No 2 (2025): September
Publisher : Lembaga Penerbitan Fakultas Kesehatan, Universitas Kristen Indonesia Maluku

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54639/kks.v4i2.1651

Abstract

Medical records are comprehensive documents that provide detailed information throughout a patient’s hospitalization. The quality of a medical record is determined by its accuracy, completeness, validity, and timeliness. This study aimed to evaluate the completeness of electronic medical records for fracture patients at Santa Elisabeth Hospital, Medan. Samples were selected using simple random sampling and Slovin’s formula. Data analysis focused on patient identity sheets, anamnesis, informed consent forms, and medical resumes. The review of medical record completeness from January to December 2024 revealed 100% completeness for patient identity sheets, 90.8% for anamnesis, and 98.7% for medical resumes. In contrast, informed consent forms had a notably low completeness rate of only 19.7%, particularly in sections requiring patient or family signatures and administrative authorization. These findings highlight the need for targeted improvements, especially in completing informed consent forms, to meet the standards for optimal medical record quality.
Co-Authors Anthonyus, Anthonyus Boris, Jev Boris, Jey Gaol, Hotmarina Lumban Ginting, Nasipta Gulo, Vivian Eliyantho Hutauruk, Adrian Hutauruk, Adrian Martin Julvian Zebua, Bernard MTI, Anthonyus Munthe, Josua Saputra Nainggolan, Sanggriani Mairanda Novitarum, Lilis Orien, Coni P.A, Lea Sri Ita Br Pasaribu, Angelia Purba, Immanuel Saragih, Helinida Saragih, Pestaria Silitonga, Novena Sanidra Simbolon, Nagoklan Simbolon, Pomarida SINABARIBA, MERLINA Sitepu, Aprilita Br Sitepu, Aprilita Br. Tarigan, Maximilianus Wira Zebua, Rezekieli