<![CDATA[Background: A method of writing progress notes that explains three things, namely what has happened to the patient, what is planned for the patient, and how the patient reacted to therapy. Based on a preliminary study conducted by researchers at the medical records installation at H. Adam Malik General Hospital, Medan, it was discovered that there were still incomplete records in the outpatient integrated service development record form, the signature and clear name of the doctor. Objective: To find out the percentage of completeness and incompleteness in filling out the outpatient integrated service progress note form and to find out the factors that cause incompleteness in filling out the outpatient integrated service progress note form. Research Method: This type of research is descriptive research with a qualitative approach. The research design used is a case study. The subjects in this study were 2 medical records unit officers. The objects in this research were 398 outpatient medical record files. Data collection techniques using interviews and documentation studies. This research was conducted via telephone due to Covid-19. Results: Based on the results of the analysis of 398 outpatient medical record files which contained an outpatient integrated service development record form, the results obtained were the percentage of completeness of recording of 398 samples of medical record files, there were 34 medical record files completely filled in and 351 incompletely filled out and 13 of them were missing. at all. The factor that causes incomplete filling is the doctor's busyness in treating patients because of the patient's condition.]]>
