Hubungan Pengetahuan Dokter Spesialis Dan Perawat Dengan Kelengkapan Pengisian Berkas Rekam Medis Pasien Rawat Inap Di Rumah Sakit Umum Daerah Dr. Soegiri Lamongan

Abstract

Background: The completeness of medical record files is very important because it affects the service process
carried out by medical staff and affects the quality of a hospital's services. This study aims to determine the
relationship between the knowledge of specialist doctors and nurses with the completeness of filling in medical
record files for inpatients at Dr. Soegiri Lamongan. Research Methods: The research method used is to use a
"cross sectional" approach. Data collection methods using questionnaires and observation check-list sheets.
Samples were taken using simple random sampling technique for specialist doctors, namely 22 people, 57 nurses
and 79 medical record files. Results: Univariate analysis using the frequency distribution and bivariate analysis
using the chi square test. The results showed that 90.9% of specialist doctors had good knowledge, 9.1% had
less knowledge. As for nurses 100% knowledgeable well. Completeness of medical record files 19.0% complete
files, 81.0% incomplete files. Based on the results of statistical tests obtained with Pearson Correlations = 0.084
(P > 0.05). Conclusion: Based on the results of the research conducted, it can be concluded that there is no
significant relationship between knowledge and the completeness of filling in the medical record files of
inpatients.
Keywords: Knowledge of Specialists and Nurses, Completeness of Medical Record Files.