(KTI) REVIEW OF THE COMPLETENESS OF OUTPATIENT FILLING MEDICAL REGISTRATION AT UPT PUSKESMAS SUNYARAGI CIREBON CITY

Filling in the components of patient identification, important format, and
authentification that are not 100% complete are still found at Sunyaragi Health Center in
Cirebon City. This study aims to determine and review the incompleteness of filling out
medical records on aspects of patient identification data, documenting important formats,
and authentication at Sunyaragi Health Center in Cirebon City.
The type and design of this study used quantitative descriptive methods. The
population is all medical record files until May 13, 2023, which amounted to 22409. The
sample in this study was 100 medical record documents. This research instrument uses
observation sheets and data collected by primary data and secondary data.
Research results that for aspects of patient identification on items of patient
name, medical record number, address, date of birth, and gender are all 100% complete.
While the head of family is 75% complete, and occupation is 54% complete. For aspects
of clinical documentation / important formats on the items of history and examination
results 99% complete, history of allergies 92% complete, history of previous illness 66%
complete, family history of illness 61% complete, IEC 95% complete, therapy 100%
complete, diagnosis 86% incomplete. For the authentication aspect, the date items were
100% complete and the name and initials of the examiner were 85% complete.
The filling of medical records at Sunyaragi Health Center in Cirebon City is not
100% complete, namely in the patient identification section, clinical documentation, and
authentication. Suggestions need to be held socialization to pay more attention to the
completeness of medical record document data so that it can improve the quality service
of Sunyaragi Health Center in Cirebon City and help to implement KLPCM after
completion of the service in order to find out incomplete documents in the filling which
was just implemented again in 2022 yesterday.