Factors That Influence The Delay Of Filling In Medical Records At The Hospital Of Rsud Dr. M.M Dunda Limboto

Abstract

Medical records are essential components of healthcare services that support continuity of care, patient safety, legal accountability, and hospital accreditation. Delays in completing medical records may reduce the quality of healthcare services and affect the effectiveness of hospital information systems. This study aimed to describe the completeness of inpatient medical records and identify factors that may contribute to delays in medical record completion at Dr. M.M. Dunda Limboto Regional Hospital. A quantitative descriptive research design was employed and conducted from April to June 2021. Data were collected through questionnaires, observations, and reviews of medical record documents from the Intensive Care Unit (ICU), Irina H, and Irina C inpatient wards. Data were analyzed using descriptive statistics and presented as frequencies and percentages. The results showed that incomplete medical records remained prevalent across the study wards. The proportion of incomplete records was 78.6% in the ICU, 49.2% in Irina H, and 63.0% in Irina C. Respondent characteristics indicated that nurses constituted the largest professional group involved in medical record documentation in all wards. Based on observations and respondent responses, delays in medical record completion may be related to discipline, knowledge, and workload among healthcare personnel. In conclusion, incomplete medical records remain a significant issue at Dr. M.M. Dunda Limboto Regional Hospital, highlighting the need for improved supervision, staff training, and workload management to support timely and complete medical record documentation.