Abstract
The quality of a good medical record must meet the indicators of completeness and accuracy of filling, timeliness in safety and provision of medical records that meet legal requirements. The purpose of this study was to analyze the influence of procedures and supervision on the quality medical records for inpatient. This research is survey research with explanatory research design. The research was conducted at Imelda Hospital. The research population was 238 people and the sample was 100 people. The sampling technique is stratified random sampling which divides the population into homogeneous groups (strata) proportionally: 21 doctors, 65 nurses, and 14 medical records officers, from each stratum a random sample is taken. Data analysis using univariate, bivariate with the chi-square test, and multivariate using multiple logistic regression tests. The results showed that the procedure factor had no effect on the quality of medical records at the Imelda Hospital, p-value 0.520> 0.05. The controlling factor influences the quality of medical records at Imelda Hospital, p-value 0.001 <0.05. The hospital implements routine surveillance with evaluations every week, every month, every six months, and every year so that medical records become of high quality, that is, medical records are complete, accurate, returned on time, and meet legal requirements.
 Keywords: medical record quality of Inpatient Care, Supervision, Procedure
Highlights
Hospital is one of the health care facilities per person in improving the health status of the community by the health development goals in Indonesia
Following the background description above regarding the issue of quality medical records, the authors are interested in researching the effect of procedures and supervision on the quality of medical records at Imelda Indonesian workers Hospital
A survey study was appllied to examine the relationship between the procedures and supervision on the quality of inpatient medical records at RSU Imelda Indonesian Workers
Summary
University of Muhammadiyah Hospital Malang, from the results of the analysis, 40 medical records provided were not complete 100% (2) It based on an analysis of 102 inpatient medical records for the June 2016 period at Dr Mental Hospital. The analysis of the integrity of International Journal of Nursing and Health Services (IJNHS), Volume 2, Issue 3, September 2019 180 filling inpatient medical record files at the Medan Hajj Hospital found that the level of completeness of medical records averaged 60% (4). Other medical record quality indicators can be assessed from the accuracy of the medical record return time and patient waiting time at registration. Following the background description above regarding the issue of quality medical records, the authors are interested in researching the effect of procedures and supervision on the quality of medical records at Imelda Indonesian workers Hospital
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