Beruflich Dokumente
Kultur Dokumente
ABSTRACT
Background: Medical records are central to all patient healthcare activities. Fundamentally, they
form part of a doctor’s ethical and statutory duty in providing good patient care.Good quality
medical records, including completeness of record filling, are essential to proper ongoing care of
the patient and are paramount for effective communication between healthcare professionals and
their patients. However, studies in Indonesia examining factors associated with the completeness
of inpatient medical record filling is scanty. The purpose of this study was to examine factors
associated with the completeness of inpatient medical record filling in a district hospital.
Subjects and Method: This was a quantitative study using a cross-sectional design, conducted at
Dr. R. Sosodoro Djatikoesomo Bojonegoro hospital, East Java, in April 2018. A total of 213 nurses
working at the inpatient service ward was selected for this study by proportional random sampling,
composing of 115 nurses with graduate degree and 35 nurses with diploma degree. The dependent
variable was completeness of inpatient medical record filling. The independent variables were
education level, employment status, tenure, responsibility, and organization support. The data
were collected by questionnaire and document review. The data were analyzed by a multiple
logistic regression.
Results: Completeness of inpatient medical record fillingwas positively associated with higher
education (OR= 2.94; CI 95%= 1.08 to 8.00; p= 0.034), civil servant status of employment (OR=
4.01; CI 95%= 1.71 to 9.40; p=0.001), ≥3 year tenure (OR= 8.84; CI 95%= 2.78 to 28.16; p<0.001),
higher knowledge (OR= 5.37; CI 95%= 1.40 to 20.55; p=0.014), stronger responsibility (OR= 3.13;
CI 95%= 1.35 to 7.28; p=0.008), and stronger organizational support (OR= 4.08; CI 95%= 1.72 to
9.67; p=0.001).
Conclusion: Completeness of inpatient medical record fillingis positively associated with higher
education, civil servant status of employment, ≥3 year tenure, higher knowledge, stronger
responsibility, and stronger organizational support.
Correspondence:
Tegar Wahyu Yudha Pratama. School of Medical Records and Health, STIKES Muhammadiyah,
Bojonegoro. Email: tegar.wahyu404@gmail.com. Mobile: +6285746085030.
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https://doi.org/10.26911/thejhpm.2018.03.01.01
and efficient care, incomplete documenta- The standard of nursing care must be filled
tion often occurs in many hospitals (Ufiti- and completed in the medical record after
nema et al., 2016). each patient's service. It is very beneficial to
Based on data from Setz and D'Inno- improve the quality of patients care and as
cenzo (2009) study conducted at the uni- a source of information on the provision of
versity hospital in SaoPaulo Brazil, the health services in hospitals.
completeness of nursing documentation is The medical record can be statedas
73.4% while 26.6% of it is incomplete. Ufiti- high quality, if the medical record can
nema et al. (2016) study which was con- describe the whole process of the service
ducted in Rwanda-Africa hospital showed correctly, completely, reliably, valid, timely,
that the completeness of nursing docu- it can be used for analysis and decision-
mentation documentation reached 67% making, uniform, constraints on standar-
while 33% of it was incomplete. In addition, dized elements consistent in its use, and
preliminary studies that have been done in easily obtained through communication
Dr. R. Sosodoro Djatikoesoemo Bojonegoro systems between health workers (Sanjoyo,
hospital showed that medical record com- 2007).
pleteness on nursing care documentation The knowledge of medical personnel
inpatient in July and August 2017, the and paramedics is generally still low on the
completeness rate still reached 75% and the filling and utilization of medical records
rest 25% was still incomplete. This is in (Hutagalung, 2005). Less nurse obedience
contrast to the regulation of the ministry of in applying documentation records of
health No. 129 / MENKES / SK / II / 2008 nursing care result in low quality comple-
on minimum hospital service standards, ments of the medical record.
stating that completeness of medical record Based on the background above, the
24 hours after completion of service (with researchers are interested in conducting a
100% complete or 0% incomplete). study on the determinant of medical record
Complete nursing care documentta- completeness in nursing care documenta-
tion has some benefits in various aspects, tion that includes education level, employ-
such as legal aspects, quality assurance, ment status, working period, knowledge,
communication, finance, education, re- responsibility and organizational support
search and accreditation (Nursalam, 2007). (agency, on completeness of filling in
In addition, according to Jefferies et al, nursing care documentation documenta-
(2010) nursing care documentation is tion in medical record at Dr. R. Sosodoro
important because it defines the nature of Djatikoesoemo hospital, Bojonegoro.
nursing itself by documenting patient care
outcomes. SUBJECTS AND METHODS
The qualified nursing care will pro- 1. Study design
vide a sense of security and comfort to the This was an analytic observational study
patients and provide a positive effect on the with a cross sectional design. The study was
healing of illness. According to the Ministry conducted in Dr. R. SosodoroDjatikoesmo
of health (2001) on the registration and hospital Bojonegoro on April 2018.
practice of nurses, Nursing care standards 2. Population and sample
include assessment, determination of The population in this study was 213 nurses
nursing diagnoses, planning, implementing in Installation of Inpatient at Dr. R. Soso-
nursing actions and nursing evaluation. doro Djatikoesmo hospital, Bojonegoro.
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Pratama et al./ Factors Associated with the Completeness of Inpatient Medical
The sample size was 150 nurses selected various sources, with a scale of categorical
with proportional random sampling based data consisting of good and lacking.
on level of education (S1: 115, D3: 35). Responsibility was defined as the
3. Study variables responsibility to bear including post control
The independent variables of this study visits, or to provide responsibility for the
included the level of education, employ- consequences. The data were measured
ment status, employment, employment using questionnaires. The measurement
status, responsibilities and organizational scale was categorical, coded 0 for poor and
support while the dependent variable was 1 for good.
the completeness of the documentation of Organizational support was defined as
nursing care inpatient care in the medical the extent to which co-workers behave in
record. supporting and strengthening employees by
4. Operational definition of variables optimizing the use of employment know-
The level of education was defined as the ledge, skills and attitudes on the job. The
highest level of formal education that has data were measured using questionnaires
been taken by nurses at Dr. R Sosodoro The measurement scale was categorical.
Djatikoesoemo hospital, Bojonegoro, with a The completeness of the medical
categorical data scale consisting of D3 and record of nursing care i was defined as s the
S1, as measured by questionnaires. documentation of nursing care (assess-
The employment status was defined ment, nursing diagnosis, nursing plan,
as the nurse status as contract or perma- implementation of nursing actions, evalua-
nent employee/civil servant in Dr. R Soso- tion, nurse's signature and nurse name,
doro Djatikoesoemo hospital Bojonegoro nursing resume, nursing record and patient
with a categorical data scale consisting of record returning or dying on the contents of
civil servants and non civil servants, as medical records. The data were measured
measured using questionnaires. by checklist. The measurement scale was
The period of work was defined as the categorical.
length of time the nurse worked since 5. Reliability Test
assigned in Dr. R. Sosodoro Djatikoesoemo Based on the reliability test on the variables
hospital Bojonegoro since the first day of of knowledge, responsibility and organiza-
work until the study was conducted. The tional support, the results can be seen in
measurement scale was categorical, coded table 1.
0 for <3 years and 1 for ≥3 years. The data 6. Data Analysis
were measured using questionnaires. Univariate data analysis of categorical data
Knowledge was defined as a person's sample was described using parameter n
knowledge that can be gained from educa- and %. Bivariate analysis was conducted
tion, training or experience derived from using Chi Square. Multivariate analysis
used a multiple logistic regression.
Table 1. Reliability Test of Questionnaire
Variable Cronbach’s Alpha Conclusion
Knowledge 0.90 Reliable
Responsibility 0.85 Reliable
Organizational Support 0.83 Reliable
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Pratama et al./ Factors Associated with the Completeness of Inpatient Medical
Table 4. The results of bivariate analysis on the factors associated with the
completeness of inpatient medical record filling
Quality of service
Variable Category Poor Good p
N % n %
Private 52 61.2 33 38.8 <0.001
Working status
Civil servants 19 29.2 46 70.8
< 3 tahun 29 82.9 6 17.1 <0.001
Tenure
≥ 3 tahun 42 47.3 73 63.5
Low 66 51.2 63 48.8 0.020
Education
High 5 23.8 16 76.2
Responsibility Poor 40 59.7 27 40.3 0.006
Good 31 37.3 52 62.7
Organizational Poor 44 58.7 31 41.3 0.005
support Good 27 36.0 48 64.0
Table 3 showed that the educational level of inpatient medical record was better (76.2%)
bachelor degree for nurse in completing the than nurses with lack of knowledge
filling of nursing care documentation on (48.8%). The result of analysis showed that
medical record was better (77.1%) than the there was a positive and significant rela-
nurses with diploma degree (45.2%). The tionship between knowledge and the com-
result of analysis showed that there was a pleteness of inpatient medical record
positive and significant relationship bet- filling.
ween educational level and the complete- Good nurse's responsibility in com-
ness of inpatient medical record filling. pleting nursing care documentation on
Civil servant status of employment in inpatient medical records was better
completing the filling of documentation of (62.7%) than nurses with less responsibility
nursing care on inpatient medical record (40.3%). The result of analysis showed that
was better (63.5%) than non-civil servant there was a positive and significant rela-
nurse (17.1%). The result of analysis showed tionship between responsibility and the
that there was a positive and significant completeness of inpatient medical record
relationship between employment status filling.
and the completeness of inpatient medical Strong organizational support to
record filling. nurses in completing the filling of nursing
The tenure ≥ 3 years in completing care documentation on inpatient medical
the nursing care documentation on inpa- records was better (64.0%) than low orga-
tient medical record was better (64.8%) nizational support to nurses (41.3%). The
than the tenure of nurse <3 years (21%). result of analysis showed that there was a
The result of analysis showed that there positive and significant relationship bet-
was a positive and significant relationship ween organizational support and the com-
between the tenure and the completeness of pleteness of inpatient medical record
inpatient medical record filling. filling.
A good nurse's knowledge in com-
pleting nursing care documentation on
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Table 5. The results of multivariate analysis on the factors associated with the
completeness of inpatient medical record filling using multiple logistic
regression
95% CI
Variable OR p
Lower Upper
Educational ≥Senior high school 2.94 1.08 8.00 0.034
Employment status (civil servant) 4.01 1.71 9.40 0.001
Tenure (≥3 years) 8.84 2.78 28.16 <0.001
Good knowledge 5.37 1.40 20.55 0.014
High responsibility 3.13 1.35 7.28 0.008
Good organizational support 4.08 1.72 9.67 0.001
N observation = 150
-2 Log Likelihood= 142.2
Nagelkerke R Square= 47.1%
Based on Table 4, the results of multiple 5.37 times probability to fill completely
logistic regression equations can be than nurses who have poor knowledge
explained as follows: (OR= 5.37; 95% CI= 1.40 to 20.55; p=
The level of education affected the 0.014).
completeness of the filling of inpatient Responsibility affected the comple-
nursing documentation on the medical teness of the filling of inpatient nursing
record which was statistically significant. documentation on the medical record
The education level of the nurses who have which was statistically significant.Nurses
bachelor degree has 2.94 times probability with good responsibility were 3.13 times
in filling completely than the diploma III more likely to fill completely than nurses
nurses (OR= 2.94; 95% CI= 1.08 to 8.00; who have lack of responsibility (OR= 3.13;
p= 0.034). 95% CI= 1.35 to 7.28; p=0.008).
Employment status affected the Organizational support affected the
completeness of inpatient nursing care completeness of the filling of inpatient
documentation in the medical record and it nursing documentation on the medical
was statistically significant. Civil servant record which was statistically significant.
status of employment has 4.01 times Nurses with good organizational support
probability to fill completely than non-civil have 4.08 times likelihood to fill completely
servant nurses (OR= 4.01; 95% CI= 1.71 to than nurses who have lack of organizational
9.40; p=0.001). support (OR= 4.08; 95% CI= 1.72 to 9.67;
Tenure affected the completeness of p= 0.001).
inpatient nursing care documentation in The score of Negelkerke R Square was
the medical record and it was statistically 47.1%, which mean that the five inde-
significant. Nurse's tenure of ≥3 years was pendent variables (educational level, em-
8.84 times more likely to fill completely ployment status, tenure, knowledge, res-
than nurses who worked for >3 years (OR= ponsibility and organizational support)
8.84; 95% CI= 2.78 to 28.16; p<0.001). were able to explain the factors that affect
Knowledge affected the completeness the completeness of filling in inpatient
of inpatient nursing care documentation in nursing care documentation at medical
the medical record and it was statistically record of 47.1% and the rest was 52.9%
significant. Good nurse’s knowledge has
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Pratama et al./ Factors Associated with the Completeness of Inpatient Medical
which explained by other factors outside (2008), civil servant nurses were more
the study. responsible for the completeness of nursing
documentation. This was also in line with a
DISCUSSIONS study by Dehghan et al, (2013) which stated
1. The effect of educational level on thatnurses who had higher employment
the completeness of inpatient status after intervention experienced an
nursing care filling on medical increase in nursing records from 25.8% to
record. 36.6%.
The result of this study showed that 3. The effect of tenure on the
educational level variable of nurses affected completeness of inpatient nursing
the completeness of inpatient nursing care care filling on medical record
filling on medical record, and it was The result of this study showed that tenure
statistically significant. variable of nurses affected the complete-
The result of this study was in line ness of inpatient nursing care filling on
with Pratiwi et al, (2014), who stated that medical record, and it was statistically
there was a relationship between nurses’ significant.
educational levels and the completeness of The result of this study was in line
nursing care documentation filling. Nurses witha study by Kumajas et al, (2014), which
who have bachelor degree and Nerscan stated that there was a meaningful relation-
completely filled the documentation assess- ship between tenure and nurse’s perfor-
ment of nursing care than the D3 nurses. A mances. This was supported by a study by
study by Moradi et.al, (2014) stated that Sofiana and Purbadi (2006) in Kumajas et
there was a significant relationship between al. (2014) which stated that nurses with a
educational level and the work quality of tenure of ≥3 years have better knowledge
nurses. In addition, a study by Okaisu et al, than nurses who have a tenure of <3 years.
(2014) indicated that staff training was According to Nursalam (2009), the longer
insufficient to achieve better nursing care the nurse's tenure, the more the nurse's
documentation, therefore, an ongoing experiences in providing nursing care in
improvement in education was needed. accordance with the applicable standards or
2. The effect of employment status on procedures.
the completeness of inpatient 4. The effect of knowledge on the
nursing care filling on medical completeness of inpatient nursing
record care filling on medical record
The result of this study showed that The result of this study showed that
employment status variable of nurses knowledge variable of nurses affected the
affected the completeness of inpatient completeness of inpatient nursing care
nursing care filling on medical record, and filling on medical record, and it was statis-
it was statistically significant. tically significant.
The result of this study was in line A study by Khoirunisa and fadilah
witha study by Maryati (2017) which stated (2017) stated that most of the nurses have
thatthe quality of medical record docu- good knowledge about nursing care docu-
ments filled by civil servant nurses was mentation which was 41 nurses (83.7%),
more complete (70%) compared to non- and there was a significant relationship
civil servant nurses (57.8%). In addition, between the level of nurse knowledge about
according to Triyanto and Kamalludin nursing documentation with the nurses'
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attitude in documenting the nursing care. documenting every action given to the
Another study by Icon et al. (2016) stated patients.
that good knowledge significantly affected A study by Titis (2014), stated that
the nursing documentation. This was sup- nursing care documentation became an
ported by Siamian et al. (2008) who stated important matter as the evidence of respon-
that there was a significant relationship sibility and accountability of nurses in
between knowledge and medical record doing their duties. In addition, Nugraha
documentation. (2012) stated thatthe nurses must be able
The nurse's knowledge determined to understand and fully understand their
the nurse's actions in providing services to responsibilities as a nurse performed by
the patient, therefore, the nurse's actions writing the complete nursing documentta-
based on the knowledge would provide tion on the prescribed sheet, because docu-
better service than the nurses who perform menting nursing care was the personal
actions that were not based on the know- responsibility of each nurse.
ledge, therefore, knowledge was very 6. The effect of organizational sup-
influential on the completeness of nursing port on the completeness of
care documentation filling (Nuryani et al., inpatient nursing care filling on
2014). In addition, according to Notoatmo- medical record
djo (2010), knowledge was a very important The result of this study showed that
factor to determine the actions of a person, organizational support variable of nurses
so that the behavior based on the know- affected the completeness of inpatient
ledge would be more long-lasting than the nursing care filling on medical record, and
behavior which was not based on know- it was statistically significant.
ledge, it mean that the higher the know- This study was in line with a study by
ledge of a person, it was expected that the Mandagi et al. (2015) which stated that
better the behavior that she/he performed. there was a significant relationship between
5. The effect of responsibility on the supervision of the leadership with the
completeness of inpatient nursing nurses’ performances in applying nursing
care filling on medical record care, in addition, there was a significant
The result of this study showed that relationship between the reward system
responsibility variable of nurses affected and the performance of nurses in applying
the completeness of inpatient nursing care nursing care. A study by Saleem (2015)
filling on medical record, and it was showed that the support from hospital
statistically significant. organization would significantly improve
The result of a study by Ulum and the nurses’ performances. In this study, the
Wulandari (2013) stated that most of the support from colleagues can improve the
nurse team (83.3%) has good responsibi- completeness of nursing care documen-
lity. This responsibility was the response- tation filling (64.0%). It was possible that
bility of providing nursing care services and support to other workers was always given
also in the recording. Another study done due to the similarity of the profession.
by Khoirunisa and Fadilah (2017) stated This statement was in line with a
that 18 nurses agreed that nursing care study byUlum andWulandari (2013), which
documentation was the nurses' duty, and stated that the support from colleagues in
nurses have to be responsible for doing a job was one of the important
things, especially in the implementation of
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