The Importance of Medical Records

Oct 13, 2025 by talynt.org 5 views

Introduction

Medical records (MRs) play a crucial role in the implementation of hospital management, particularly in efforts to improve service quality. Unfortunately, at the Sigli General Hospital Health Services Agency (BPK), only about 30% of MRs are filled in completely. This is caused by the behavior of specialist doctors who do not care about the completeness of the MR filling. However, it still needs to be further investigated whether the low filling is caused by the factor of "uncertainty" or "ignorance" about how to fill MR well.

The Importance of Medical Records

Medical records are a written record of health services provided by a doctor to patients. They contain vital information about a patient's medical history, diagnosis, treatment, and progress. MRs are essential for several reasons:

Quality of care: MRs help healthcare providers to make informed decisions about patient care, ensuring that patients receive the best possible treatment.
Patient safety: MRs help to identify potential errors and near misses, reducing the risk of adverse events.
Research and education: MRs provide valuable data for research and education, helping to improve healthcare outcomes and patient care.

The Role of Specialist Doctors in Filling Medical Records

Specialist doctors play a critical role in filling MRs. They are responsible for documenting patient information, including medical history, diagnosis, treatment, and progress. However, many specialist doctors do not prioritize MR filling, leading to incomplete and inaccurate records.

The Relationship Between Knowledge and Motivation with the Behavior of Specialist Doctors

This study aims to analyze the relationship between knowledge and work motivation with the behavior of specialist doctors in filling MRs. The method used is an analytical survey, which observes nine specialist doctors at BPK Sigli Hospital. Data was collected through a medical record checklist filled by doctors from October to December 2007, as well as through interviews and questionnaires measured using the Likert scale.

Results

The results showed that most specialist doctors at BPK Sigli Hospital had good knowledge about MRs. On the motivation side, 66.7% of doctors stated that the supervision they received was at a good level, and 44.5% stated good working conditions. Related to the job itself, 66.7% of doctors felt their work interesting. However, recognition from superiors does not show a significant relationship with the MR filling behavior.

Discussion

Data shows that knowledge, supervision, working conditions, and work nature have a significant relationship with the MR filling behavior. Conversely, recognition variables do not show significant effects. From this result, it can be concluded that the incompleteness of MRs at BPK Sigli Hospital was caused by the lack of motivation and socialization of management regarding the importance of filling MRs.

Recommendations

Recommendations for the management of BPK Sigli Hospital are considering the appropriate reward to increase the motivation of doctors in filling MRs. In addition, there needs to be an increase in socialization regarding regulations and laws governing MRs. Increasing this understanding and support is expected to improve the quality of MR filling and have a positive impact on the quality of health services in the hospital.

Conclusion

By paying attention to the results of this study, it is hoped that there will be concrete steps from hospital management to increase the motivation and knowledge of specialist doctors in filling MRs, for the achievement of better health services.

Limitations

This study has several limitations:

Small sample size: The study only observed nine specialist doctors, which may not be representative of the entire hospital.
Limited data collection: The study only collected data through a medical record checklist, interviews, and questionnaires, which may not provide a comprehensive understanding of the issue.

Future Research Directions

Future research should aim to:

Increase the sample size: A larger sample size would provide a more representative understanding of the issue.
Collect more data: Collecting more data through various methods, such as surveys, interviews, and observations, would provide a more comprehensive understanding of the issue.
Explore other factors: Exploring other factors that may influence MR filling behavior, such as patient satisfaction and staff engagement, would provide a more nuanced understanding of the issue.

Q: What is the significance of medical records in hospital management?

A: Medical records play a crucial role in the implementation of hospital management, particularly in efforts to improve service quality. They contain vital information about a patient's medical history, diagnosis, treatment, and progress.

Q: Why are medical records not being filled in completely at the Sigli General Hospital Health Services Agency (BPK)?

A: The incompleteness of medical records at BPK is caused by the behavior of specialist doctors who do not care about the completeness of the medical record filling.

Q: What is the relationship between knowledge and motivation with the behavior of specialist doctors in filling medical records?

A: The study found that knowledge, supervision, working conditions, and work nature have a significant relationship with the medical record filling behavior. Conversely, recognition variables do not show significant effects.

Q: What are the recommendations for the management of BPK Sigli Hospital to improve medical record filling behavior?

A: Recommendations for the management of BPK Sigli Hospital are considering the appropriate reward to increase the motivation of doctors in filling medical records. In addition, there needs to be an increase in socialization regarding regulations and laws governing medical records.

Q: What are the limitations of this study?

A: This study has several limitations, including a small sample size and limited data collection.

Q: What are the future research directions for this study?

A: Future research should aim to increase the sample size, collect more data, and explore other factors that may influence medical record filling behavior.

Q: How can hospital management improve medical record filling behavior?

A: Hospital management can improve medical record filling behavior by increasing the motivation of doctors through appropriate rewards and socialization regarding regulations and laws governing medical records.

Q: What is the expected outcome of improving medical record filling behavior?

A: The expected outcome of improving medical record filling behavior is to improve the quality of medical records and have a positive impact on the quality of health services in the hospital.

Q: How can patients benefit from improved medical record filling behavior?

A: Patients can benefit from improved medical record filling behavior by receiving better quality care, improved patient safety, and more accurate and comprehensive medical records.

Q: What is the role of specialist doctors in filling medical records?

A: Specialist doctors play a critical role in filling medical records. They are responsible for documenting patient information, including medical history, diagnosis, treatment, and progress.

Q: Why is it essential to prioritize medical record filling behavior?

A: It is essential to prioritize medical record filling behavior because it has a direct impact on patient care, patient safety, and the quality of health services in the hospital.