Determinasi Faktor Individu terhadap Kelengkapan Pengisian Rekam Medis oleh Tenaga Kesehatan
Abstract
Completeness of medical record documentation was an essential component of healthcare quality that supported patient safety, continuity of care, and hospital legal accountability. Individual factors such as knowledge, attitude, and work experience were assumed to influence healthcare workers’ compliance with medical documentation standards. This study aimed to analyze the effect of individual factors on the completeness of medical record documentation among healthcare workers at Hospital X. A cross-sectional design was applied, involving 82 healthcare workers selected through stratified random sampling. Data were collected using a structured questionnaire and observation sheet that had been tested for validity and reliability. Data were analyzed using Chi-square and multiple logistic regression with a significance level of 0.05. The results showed that most respondents had high knowledge (85.4%) and positive attitudes (75.6%). Bivariate analysis revealed significant relationships between knowledge and attitude with the completeness of medical record documentation (p=0.000). Multivariate analysis revealed that only knowledge had a significant effect on medical record completeness (OR=0.068; p=0.001), while attitude was not statistically significant. This study concludes that knowledge is the main determinant of complete medical record documentation. Strengthening knowledge through continuous training, medical record audits, and structured feedback is necessary to improve the quality of medical documentation in healthcare facilities.
Keyword: medical record, knowledge, attitude, healthcare workers, documentation completeness
Abstrak
Kelengkapan pengisian rekam medis merupakan bagian penting dari mutu pelayanan kesehatan yang mendukung keselamatan pasien, kesinambungan asuhan, dan akuntabilitas hukum rumah sakit. Faktor individu seperti pengetahuan, sikap, dan pengalaman kerja diduga memengaruhi tingkat kepatuhan tenaga kesehatan terhadap standar dokumentasi medis. Penelitian ini bertujuan untuk menganalisis pengaruh faktor individu terhadap kelengkapan pengisian rekam medis oleh tenaga kesehatan di Rumah Sakit X. Penelitian ini menggunakan studi cross-sectional dengan jumlah responden sebanyak 82 tenaga kesehatan yang dipilih melalui stratified random sampling. Data dikumpulkan menggunakan kuesioner terstruktur dan lembar observasi yang telah diuji validitas dan reliabilitasnya. Analisis dilakukan menggunakan uji chi-square dan regresi logistik berganda dengan tingkat signifikansi 0,05. Hasil penelitian menunjukkan bahwa sebagian besar responden memiliki pengetahuan tinggi (85,4%) dan sikap positif (75,6%). Uji bivariat menunjukkan hubungan yang signifikan antara pengetahuan dan sikap dengan kelengkapan pengisian rekam medis (p=0,000). Hasil analisis multivariat menunjukkan bahwa hanya pengetahuan yang berpengaruh signifikan terhadap kelengkapan pengisian rekam medis (OR=0,068; p=0,001), sedangkan sikap tidak menunjukkan pengaruh yang signifikan. Penelitian ini menyimpulkan bahwa pengetahuan merupakan faktor determinan utama dalam kelengkapan pengisian rekam medis. Penguatan pengetahuan melalui pelatihan berkelanjutan, audit rekam medis, dan umpan balik terstruktur diperlukan untuk meningkatkan mutu dokumentasi medis di fasilitas pelayanan kesehatan.
Kata Kunci: rekam medis, pengetahuan, sikap, tenaga kesehatan, kelengkapan dokumentasi
Keywords
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DOI: https://doi.org/10.47007/inohim.v13i2.744
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