| Summary: | Background: To date, the completeness of medical record remains become main problem in the hospital information management. The core of the health information system in the hospital lies in the medical record, which contain all the data concerning diseases and practices. Therefore it s important to make a review on the completeness of the medical record and perform a trial to enhance the quality of the medical record in the teaching hospital Sardjito Hospital, as a teaching take a huge responsibility in producing a professional clinicians medicinal and administratively. Method: The objectives of this study were to identify the completeness of medical record, and to analyze the differences on the completeness of medical record before and after training programmed. The location frames in the Pediatric ward of Sardjito Teaching Hospital. A quasy experiment model, an after and before study without control groups, was adopted in this study. The medical record before the study became base line data, and the one after training would be the next data to compare to the previous. Training programmed as the predictor variable to influence the completeness of medical record as the criterion variable, which were represented on the assessment by the residences as a trainee, who have responsibility in patients medical record. A statistical method was used to analyze the specific differences qualitatively.
Result and conclusions: As result, in 30 section of 92 couple medical record, it is found that 4 of them decreased after were implemented. But rest, were increasing significantly. Statistically, training program influenced the completeness of medical record after training program, compared to medical record full-filled before training program, at t-value: 3,66 on 0,0012-tail significance. Though, as the main target on the training, ICD-X code and on the time returning, were still poor and under the international standard.
Keywords: completeness of medical record, training program
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