ANALYSIS OF THE COMPLETENESS OF MEDICAL RECORDS OF PATIENTS IN TRAFFIC ACCIDENT CASES IN THE INPATIENT UNIT CLASS III ROOM BHAYANGKARA TK IV GORONTALO HOSPITAL

Abstract

This study aims to examine and analyze the completeness of medical records of patients in traffic accident cases treated in class III at Bhayangkara TK IV Gorontalo Hospital and find out how to identify the factors that influence the completeness of medical records. This research method uses a qualitative approach with the type of research used in this research being descriptive research. This research obtained information through in-depth interviews with 5 informants consisting of the Head of Medical Records, Medical Records Officer, Head of Class III Inpatient Room, Inpatient Nurse, Class III Inpatient Administrator. The results of the research show that recording patient identities at Bhayangkara TK IV Gorontalo Hospital has been carried out in accordance with detailed procedures, but there are still errors or incompleteness due to staff negligence. Important reports such as laboratory and radiology results run well with SIMRS support, but there is still manual recording which risks causing delays. The authentication process required re-verification due to suboptimal SIMRS integration and lack of staff training. Medical record documentation is generally complete, but challenges such as time, workload and technical issues still impact quality, requiring increased auditing and regular training to improve the system and ensure data accuracy.