The Importance of Nurse Knowledge about Physical Examination

and Inform on Medical Record Facility Inpatient Patient: Case Study

in Sari Asih Hospital Karawaci Tangerang

Astri Annatasia

, M. Reza Hilm

, Rokiah Kusuma

rad

and Erlina Pus

italoka Mahadewi

Master Program Adminsitrasi Hospital (S2, Esa Unggul University Jakarta

Faculty of Health Sciences, Esa Unggul University Jakarta

Keywords: medical records, knowledge, inpatients.

Abstract: Based on the results of the observation in Sari Asih Hospital Karawaci Tangerang obtained medical record

of hospitalized records are still many empty is that in 2016 there are 296 (3.4%) patients and in 2017 there

are 405 (3.9%) patients. The incompleteness of medical record data mostly occurred on the accuracy of

patient identity (name, a medical record number, place of birth date, sex) that is 37 patients (9%); and

physical examination of 44 patients (11%), informed consent 47 (12%). The nurse's function as one of the

data inputs that make the documentation of nursing care actions will affect the quality of the patient's

medical records. The incompleteness of DRM is because there are still many nurses who have poor

knowledge (60%) about medical records.The purpose of this research is to determine the effect of

knowledge of nurses in filling out medical records on the completeness of medical records file of inpatients

(case study in Rs. Sari Asih Karawaci Tangerang). The design of this study is associative causal (causal)

with a quantitative approach. The object of this research is nurses in hospital wards as much,and samples

counted 25 people with purposive sampling technique. Data collection by using primary data in the form of

questionnaire/questionnaire and secondary data based on RM 2017 data which then analyzed by binary

logistic regression analysis.Based on the result of regression logistic binary statistical analysis, it is found

that the nurses' knowledge variable in the filling of the medical record has a significant effect on the

accuracy of the medical records file of the inpatients The better the nurse's knowledge,the more complete

the patient's medical record. Advice for hospitals to socialize, regularly monitor and evaluatenurses, about

the importance of completeness in filling the medical record.

1 BACKGROUND

Hospitals are health referrals that serve

outpatients, emergency and inpatient care with

various types of medical services and medical

support in a hospital service system. Serving the

patient is one of the hospital services, in accordance

with the Regulation of Medical Record (RM) in

accordance with the Regulation of the Minister of

Health of the Republic of Indonesia Number 269 /

Menkes / PER / III / 2008 dated 02 March 2008 on

Medical Record. Also described medical record is a

file containing records and documents about the

patient's identity, treatment examinations, actions

and other services that have been given to the

patient. Medical records should be in writing,

complete and clear or electronically.

There is already a fixed procedure (attached)

about the completeness of medical records data in

inpatient turned out from the observations in "RS

Sari Asih Tangerang" in the assembling in the

implementation of his duties generated data medical

records hospitalized records are still many empty.

RS Data. Sari Asih Karawaci Tangerang in 2016

showed 8,793 (14.7%) of inpatients from 59,993

patients overall, from 8,793 inpatients there were

296 (3.4%) patients with incomplete medical record

data. While in 2017 it showed an increase in

hospitalized patients to 10,308 out of 85,947 patients

as a whole, and from 10,308 inpatients there were

405 (3.9%) patients with incomplete medical record

data. The incompleteness of medical record data

mostly occurred in the patient accuracy of patient

identity (name, a medical record number, place of

birth date, sex) that is 37 patients (9%); and physical

Annatasia, A., Hilmy, M., Kusumapradja, R. and Puspitaloka Mahadewi, E.

The Importance of Nurse Knowledge about Physical Examination and Inform on Medical Record Facility Inpatient Patient: Case Study in Sari Asih Hospital Karawaci Tangerang.

DOI: 10.5220/0009950704910498

In Proceedings of the 1st International Conference on Recent Innovations (ICRI 2018), pages 491-498

ISBN: 978-989-758-458-9

491

examination 44 patients (11%), informed consent 47

(12%)

The nurse's function as input data made from the

nursing care actions performed will affect the poor

quality of information in the patient's medical

records. Better health data quality in the patient's

medical record can be reviewed by and therefore

requires a good knowledge of the nurse.

Knowledge of medical records, in this case, is

the knowledge of what should be accomplished in

the filling example of medical records other than

that how to create a medical record correctly in

accordance withPermenkes (2008) consisting of

patient identification, treatment examinations,

actions and other services that have been given to

the patient

Initial survey conducted by the researchers

resulted in data that there are still many nurses who

have poor knowledge (60%) about the medical

record.

The existence of this study is expected to

contribute or its application, especially for nurses

about the filling of medical records

This motivation is to improve the knowledge

about the medical record so that the quality of

medical record becomes better and better quality.

2 RESEARCH METHODS

This research method using research method

with a quantitative approach to know the significant

relationship between variables studied. The

technique used in this study is to determine the

sample size of the population is a purposive

sampling technique. Data analysis used binary

logistic regression analysis. Sari Asih Karawaci

Tangerang with one shot time horizon to study that

is research done with the previous study, week,

week, in order to answer the research question

OPERATIONAL DEFINITIONS VARIABLES

In this study the dependent variable (Y) is the

completeness of the medical record is a file

containing records and documents about the identity,

examination, treatment, action, and other services

that have been given to the patient in the form of

physical examination data and informed consent

with the instrument of the questionnaire based on

medical records of RS Sari Asih Tangerang in 2017

with interval scale. While the independent variable

(X) is the knowledge of the nurse that is knowledge

about what should be completed in the filling of

medical record file and Understanding the correct

way of writing medical records file in accordance

with Permenkes year 2008 with instrument is a

questionnaire consisting of 15 items of questions

with interval scale

2.1 Research Result

The result of research is shown in the frequency

distribution of respondent characteristics as follows:

Table 1: Characteristics of Nurse RS Sari Asih Karawaci

Tangerang

No Characteristics of

Respondents

Amount %

1. Age

20-26 years old 6 24

27-40 years old 15 60

41-61 years old 4 16

2. Last education

SPK 0 0

DIII 13 52

S1 8 32

S2 4 16

3. Years Of Work

< 1 year 2 8

< 5 year 5 20

< 10 year 10 40

> 10 year 8 32

4. Gender

Man 7 28

Woman 18 72

Source: data that has been processed (2018)

Based on Table 4.1 above, respondents are

mostly aged 27-40 years, 60%, most respondents

have recent education DIII (52%), work-based

characteristics are mostly found <10 years (40%)

and most of them are female (72%).

2.2 Variable Descriptive Satistics

Table 2: Results Descriptive Statistics Variable

Variabe

N Mini

mum

xim

Mean

Std

Deviation

Knowle

dge

25 6 15 11.40

2.90115

Complet

Medical

Record

25 32 37 36.12

1.56312

Vallid

(N)

Source: data that has been processed, SPSS 24

ICRI 2018 - International Conference Recent Innovation

492

Output table 4.2 above shows the value of N or

the amount of data to be studied amounted to 25

samples. The nurse's knowledge about the filling of

medical record file has mean or a mean value of

11.40 which means that the average knowledge of

the nurses is included in either category with a

maximum value of 15 and a minimum value of 6

With a standard deviation of 2.90115 it can be said

the average value of deviation of knowledge

variables is 2.9%. Furthermore, for medical record

completeness variable obtained mean or mean value

of 36.12 which means the average completeness of

medical records file included in the category either

with a maximum value of 37 and a minimum value

of 32. With the standard deviation 1.56312 can be

said the average value of deviation variable the

completeness of the medical record is 1.56%.

The descriptive results of each variable based on

the number of presentations are as follows :

StatisticsTest

1. ValidityTest:The test results of instrument

validity to 10 respondents are as follows:

Table 3: Validity Test Results

Source: data that has been processed, SPSS 24

The table above shows that all the question items

in this study are valid. Where r table value with the

number of respondents (N = 10 or df (N-2) = 8) and

the significance level of 0.05 is 0.6139. The r

valueof the whole question is greater than r table,

which means the question items in the questionnaire

have met the validity requirements

2. ReliabilityTest

Next is the reliability test of the questionnaire by

taking 10 samples of Inpatient Patients BPJS Sari

Asih Ciledug Hospital is processed using a

computerized system with the softwareSPSS version

24 is:

Table 4: Reliability Test

Variable Cronbach’s

Alpha

Conclusion

Nurse Knowledge

About Medical

Record

0.975 Reliable

Source: Primary data that is processed (2018)

In table 4.4 it can be seen that the knowledge

variable of medical record file has Cronbach's Alpha

(α) above 0.60 so it can be said that all the concepts

of variable measuring of the questionnaire are

reliable which means that the questionnaire used in

this study is a reliable questionnaire to be analyzed

Furthermore.

1. Wald Test

Table 5: Wald Test

Wald df Sig. conclusion

Step 1

Medical

Record

Completen

ess

11.000 1 .006 Be

accepted

Constant 1.199 1 .000

Source: Primary data that is processed (2018)

Based on table 4.5 above can be seen that the

value of wald by 11,000 with the value of sig 0.000

<0.05 (5%), it can be concluded that the hypothesis

accepted the knowledge variable significantly affect

the completeness of the medical record file.

2. Coefficient of Determination Test Nagelkerke

R Square

Table 6: Nagelkerke R Square Test

Step -2 Log likelihood

Cox &

Snell R

Square

Nagelkerke R

Square

1 8.376

.486 .769

Source: Primary data that is processed (2018)

Based on the results of Nagelkerke R square test

obtained value of 0.769 which means then the

proportion of completeness of the medical record

file that can be explained by 76.9%. while the

remaining 23.1% can be explained by other

variables outside the research model such as

attitudes, beliefs, beliefs of values, physical

environment (facilities or health facilities), attitudes

and behavior of health workers or other officers.

The Importance of Nurse Knowledge about Physical Examination and Inform on Medical Record Facility Inpatient Patient: Case Study in

Sari Asih Hospital Karawaci Tangerang

493

3 DISCUSSION

3.1 Univariate Analysis

3.1.1 Nurse Knowledge in Charging Medical

Record Files

The knowledge that is discussed in this research

that is about a medical record that is knowing what

must be completed in filling out medical record file

and understand how to write medical record file

correctly in accordance with Permenkes year 2008

consisting of writing name, contact person address,

record number medical and patient age etc. (Shofari,

2006). According to Permenkes No. 269 In 2008, the

medical record is a file containing records and

documents such as patient identity, examination

results, a medication that has been given, and other

actions and services that have been given to the

patient. The purpose of the medical record is to

support the achievement of orderly administration in

order to improve health services. Without the

support of a proper medical record management

system, then the administrative order will not

succeed (Gondodiputro, 2007). The scale assessment

of knowledge categories based on Budiman and

Riyanto (2013) are grouped into two groups:

1) Knowledge level category Good value> 50%

2) Knowledge level category Less good value ≤ 50%

In this research obtained most of the knowledge

of nurses included in the good category as many as

20 people (80%). While as many as 5 people with

less good knowledge (20%) as for the score answer

each question item on the questionnaire knowledge

sheet as follows.

Table 7: Respondents answer Score

No Question Score (%)

1. At least the things that should be

included in the medical record

are identity, anamnesis, physical

examination, and diagnosis

15 60

2. Medical Records on the patient's

physical examination include

information such as inspection,

palpation, percussion and

auscultation

21 84

3. Medical Record regarding the

physical examination of the

patient contains the patient's

nursing history

23 92

4. Medical Record regarding the

physical examination of the

patient at least contains the

height of the body (TB), weight

23 92

No Question Score (%)

(BB), temperature, and

pulse/pulse frequency.

5. Medical Record results have to

be complete within 24 hours

after the patient is treated and

before the surgery

22 88

6. Medical Record physical

examination contains the history

and the course of the patient's

illness

23 92

7. Medical Record physical

examination contains diagnosis

and patient laboratory results

22 88

8. In the Medical Record form of

Informed consent contains the

consent of the medical treatment

signed by the patient/family of

the patient concerned

beforecertainactions/therapies

9 36

9. In the Medical Record form of

Informed consent contains the

consent obtained by a physician

before any medical examination,

treatment, and medical action to

be performed for the patient's

healing

16 64

10. The Medical Record form

informed consent contains the

patient's identity (Name, date of

birth, Gender, address, ID / ID /

SIM, no phone)

23 92

11. The Medical Record form

informed consent form must be

signed by the patient/patient's

family 24 hours before any

medical action is taken

22 88

12. The Medical Record form

informed consent form is known

and signed by both witnesses,

the nurse acting as one of the

witnesses

21 84

13. The Medical Record form

informed consent form must be

stamped

14 56

14. The Medical Record form

informed consent form is not

required for emergency patients

who are not accompanied by the

patient's family

7 28

15. The Medical Record form

informed consent form must be

signed by the physician as the

person in charge of the written

information

Source: Primary data that is processed (2018)

Fromdata can be seen for the medical record

physical examination of the lowest score on the item

question 1 with a score of 15 (60%) ie at least things

that should be included in the medical record is

identity, anamnesis, physical examination and

diagnosis when for file recording especially in

inpatients must contain at least about the identity of

ICRI 2018 - International Conference Recent Innovation

494

the data, date and time, the results of the history, the

results of physical examination, investigation,

diagnosis, management plan, treatment, observation

record, home summary, name and sign of doctor /

dentist for dental cases equipped with odontogram.

Further scores on item no. 2 of 21 (84%) with RM

note notes regarding physical examination of the

patient include information in the form of

inspection, palpation, percussion and auscultation.

Though it should be information of RM physical

examination not only that but also include an

examination of the head to toe which contains the

result of the check of vital signs (temperature, blood

pressure, pulse, respiratory rate) and basicbiometric

(TB, BB, Pain).

As for the informed consent, the lowest score on

item no 14 (7%) is the RM informed consent form

not required for emergency patients who are not

accompanied by the patient's family. In this

question, many nurses who assume in emergency

conditions must continue to fill in informed consent.

Whereas according to Permenkes No 209 / Menkes /

Per / III / 2008 in Article 4 paragraph (1) that no

informed consent needed in emergencies. However,

if an action has been taken to rescue the emergency,

the physician is obliged after that to explain to the

patient or immediate family.

The next lowest score on item 8 with a score of 9

(36%) with the question on the RM form of

Informed consent contains the consent of the

medical treatment signed by the patient/family of the

patient before any specific action/therapyis

performed. Many nurses consider informed consent

only for certain therapies. Whereas informed consent

is written and oral consent which is done for all

medical actions in normal circumstances and

emergency situations.

Overall nurse knowledge about RM physical

examination and informed consent included in good

category, this can be seen from the mean value of

11.40.

The results of this study in line with research

conducted by Agus Siswanto in 2012 obtained the

results of nurse knowledge about the regulation of

medical record in the category very good 43.6%,

both 25.5%, quite 23.6%, and less 7.3% . Another

study conducted by Ardika (2012) found that 11

people (73.3%) who know medical records in either

category.

The low score on statement item # 1 concerning

the inclusion of minimal data on medical record

documents is very fatal because most respondents

answered wrongly (60%). Similarly, question no 2 is

about RM records on physical examination of the

patient. This proves that there are still many nurses

who do not know about the procedure of filling the

medical record correctly. According to the medical

record document, researchers should be given

sufficiently detailed data, as this relates to treatment

and care to the patient and the implementation of

further examination to the patient. As for the

informed consent the lowest score on item No. 8 and

14. This indicates that many nurses who do not

understand the use of informed consent.

The nurse as one of the medical record personnel

has the responsibility to evaluate the quality of the

medical record itself to ensure consistency and

completeness of the content. Therefore, the RM

report, in this case, the physical examination and

informed consent is in full condition and contains all

positive and negative discovery data.

According to the researcher the good level of

knowledge by the nurse this is caused by 60% age of

respondents are in the range of 27-40 years it shows

the nurse at productive age to produce good

performance besides the highest nurse education

level is DIII (52%) and work experience <10 years

(40%) this is also a good input for nurse knowledge

because education influences the learning process,

the higher the education of a person the easier it is

for the person to receive the information. With

higher education then one will tend to get

information both from others and from the mass

media. The more information that goes in,the more

knowledge gained about health. Knowledge is

closely related to education where it is expected that

someone with higher education then the person will

be more knowledgeable. Further experience or high

work can increase the knowledge of nurses because

experience as a source of knowledge is a way to

obtain the truth of knowledge by repeating the

knowledge gained in solving problems faced in the

past so that with long service can develop a person's

ability to increase knowledge.

Also, nurses who have a good knowledge of

medical records (80%) are nurses who are always

active to find out about SOP filling the medical

record. While 20% of nurses with knowledge of

filling the medical record is not good, this is

according to the researcher because the nurses are

not active to seek information about medical records

either ask through RM officers, doctors, midwives,

verifieretc. and never participate in training and

workshop about medical record. Nurses who do not

yet have a good knowledge of medical records are

usually new nurses who have not been input from

long-standing nurses with good experience in filling

out medical record data. According to Notoatmodjo

The Importance of Nurse Knowledge about Physical Examination and Inform on Medical Record Facility Inpatient Patient: Case Study in

Sari Asih Hospital Karawaci Tangerang

495

(2010), the source of certain knowledge possessed

and controlled by a person is obtained through

experience, both individually and in society.

3.1.2 Medical Record Completeness

Medical records according to the Indonesian

Minister of Health Regulation 269 / MENKES /

PER / III / 2008 are files containing records and

documents on identities, checks, medications,

actions and other services that have been provided to

patients. The completeness of medical records is of

great importance because the complete medical

resume in addition to maintaining the quality of

medical records is also used for the administration of

insurance claims (Anggraini, 2013)

Referred to the completeness of medical records

in this study is the completeness of medical records

documents viewed regarding clinical examination

and informed consent.

Based on this research, the researcher get the

result of the contents of the medical record

document of inpatient patient of BPJS in Asari

Karawaci Hospital of Tangerang in 2017, is as

follows: from 25 samples of medical record

document there are 18 medical record documents

complete with percentage 72%, while medical

record which is incomplete there are 7 with a

percentage of 28%.

The result of this research is in line with the

research conducted by Ardika (2012) which is 10

documents RM (66,7%) that fulfill the complete

category.

Physical examination is a physical examination

in the whole body of the client's examination,or only

a certain part is deemed necessary, to obtain

systematic and comprehensive data to ensure/prove

the results of anamnesis, determine the problem and

plan appropriate nursing actions for the client (Dewi

Sartika, 2010)

In this research for Medical Record Form of

Physical Examination there are 5 RM files of patient

with incomplete field that is on:

(1) High Body Examination (TB)

Height is a measure of the size of a human

body in height measured in pure state of height

from heel to head without any other object being

measured (Setyapranomo 2017).

In this research data Medical record TB

incomplete according to the researchers, this is

because there are still nurses who are not

disciplined in the filling fil records RM record

(2) Mental Status

The mental status examination includes

mental status assessment, awareness assessment,

psychomotor activity assessment, orientation

assessment, perceptual assessment, form and

thought content assessment, mood and affective

assessment, impulse control assessment, reality

valuation assessment, insight assessment,

functional ability assessment (MOH, 2010)

In this research medical record data mental

status incomplete according to the researchers

this is because there are still nurses who are not

disciplined in the filling completelyMedical

record.

(3) Genital Devices

Genitalia Physical Examination is to find out

whether the client has a problem with genitalia

(vital tool) both internally and externally.

According to researchers physical

examination of the patient's genitals can make

the client feel ashamed,sonurses should take a

quiet approach. The gynecological examination

is a difficult experience for the patient. Also,

there are cultural restrictions.Therefore there are

still nurses who do not perform a physical

examination of the genitals in patients.

Next, on the Informed Consent form,6 RM

patient files are incomplete which include:

(1) No identity (KTP/SIM) of the patient

(2) TTL family members (* authorized)

(3) No identity (KTP/SIM) of family member (*

authorized)

(4) Signature of the witness of the patient

Informed consent is incomplete according

to the researcher because the patient/family

of the patient did not complete the form at the

time of consultation. Therefore the nurse

should be careful and careful inquiries and

should ensure that questions asked on the

form are clear and understandable by the

patient

3.1.3 Nurse Knowledge in Charging Medical

Record on Medical Files Record

Completeness

Based on the results of research that has been

described previously it is obtained data that there is a

significant influence between nurse knowledge

variables in the filling of medical records to the

completeness of medical records file it can be seen

in table 4.3 that is obtained wald value of 11,000

with the value of sig 0.000 <0.05 (5% ), then the

influence of knowledge variable with the

ICRI 2018 - International Conference Recent Innovation

496

completeness of medical record is 76.9% this is

proven by the test of nagelkerke R square (Table

4.5). While the remaining 23.1% affect the

completeness of medical records by other variables

that are not examined such as attitudes, beliefs,

beliefs values, physical environment (facilities or

health facilities), attitudes and behavior of health

workers or other officers.

The results of this study are in line with research

conducted by Utami (2016) which states that there is

a meaningful relationship between nurse knowledge

about the medical record with the completeness of

nursing note at the inpatient installation at Al AT-

Turots Al-Islamy Sleman General Hospital (p =

0.006). Another study conducted by Agung Personal

(2011) suggests that low-knowledge nurses risk

6.280 times greater for incomplete documentation.

According to the Minister of Health Number 269

of 2008, the documentation of medical record file is

started when the patient is admitted to the inpatient

ward, the receiving nurse must fill out the recording

form starting from the identity (name and patient RM

number), the report should include data assessment,

diagnosis, nursing actions, and the execution and

evaluation of actions when carrying them out, then

continued with authentication (affixing doctor's name

and signature). The medical record resume is

completed by the nurse as soon as the patient is

declared allowed to go home by the doctor, or go

home at his request, or dies. From this, it can be

concluded the completeness of medical records file is

very important to support the performance of health

practice. Ardika (2012) states the completeness of

documenting the medical record is influenced by

various factors such as educational background,

length of service, knowledge, skills, motivation,

psychological and so forth.

Of the 7 incomplete medical record documents,

were analyzed further without the use of statistical

tests and obtained results that nurses filled the

document with an uneven distribution of age from 22

to 33 years old and they were mostly graduates from

nursing school (SPK). The data obtained on the

educational background of the research samples

showed 48% were graduates of undergraduate

nursing (S1) and S2 they have knowledge about the

good medical record and complete the documentation

of nursing care completely.

While the other 52% who are graduates from the

SPK, nursing academy (DIII) and perform the

process of documentation with different levels of

completeness. This difference in completeness may

be due to the lack of knowledge, awareness and

motivation of the nurse to complete the

documentation process. Also, SPK education and

academy is a beginner profession education so that in

the implementation of its work requires experience

and training enough to be able to do the job well.

Knowledge is very important in forming one's

behavior, hence from the result of this research

indicate that the better the nurse’knowledge about

filling of medical record file hence more complete

data of patient medical record. Therefore, for RS

Sari Asih Karawaci Tangerang to maintain and even

improve the knowledge of medical record officer for

the implementation of hospital management system

by conducting training or seminar related to the

medical record.

3 CONCLUSION

Based on the results of research on the Influence

of Nurses' Knowledge in Filling Medical Records

Against Completeness of Medical Record Files

Inpatient Patients at RS. Sari Asih Karawaci

Tangerang Year 2017, it can be concluded as the

most of the knowledge of nurses in the filling of

medical records file included in good category

(80%), then most of the completeness of medical

records file of inpatients included in complete

category (72%). The result of the statistical test

showed that there was significant influence between

the nurse knowledge variable in filling the medical

record to the completeness of the medical record

file. This was proved by the wald test value of

11,000 and the sig value 0.000 <0.05

The nurse's knowledge about charging RM will

affect the quality of the medical record which

ultimately also affect the hospital administration.

Because as the main objective of the medical record

is to support the achievement of the administrative

order to improve health service in the hospital,

without support by a system of medical record

management good and correct, orderly hospital

administration will not succeed as expected. Also,

incomplete medical record data resulted in delays

from Claim payments submitted by the Hospital

which will also affect the hospital operations is the

obstruction of Hospital cash flow (cashflow).

4 IMPLICATIONS

1. There should be an education, workshop

training, and seminar related to medical record

to improve the knowledge of the nurse

The Importance of Nurse Knowledge about Physical Examination and Inform on Medical Record Facility Inpatient Patient: Case Study in

Sari Asih Hospital Karawaci Tangerang

497

2. The nursing perception among nursing staff

about filling the completeness of medical

records file so that all nurses can perform their

duty well according to SOP.

3. Nurses should be careful and careful inquiries

and should ensure that questions asked on the

informed consent form are clear and

understood by the patient

4. Preferably for newly employed nurses from the

beginning of the orientation given the

knowledge and advance about the importance

of the completeness of the inpatient medical

record file

5. To the management of RS to activate the

function of medical record committee in charge

of planning, implementation, supervision,

controlling, audit and assessment of medical

service quality according to the guideline of the

medical record of MOHRI so as to improve the

quality of hospital service.

5 SUGGESTION

1. Need to do further research to find other factors

that influence the completeness of the patient's

medical record

2. Nurses are expected to carry out a fixed

procedure or SOP on filling in the

completeness of the existing medical records

file

3. For the management of Sari Asih Hospital

Karawaci Tangerang to socialize,

regularlymonitor and evaluate to health

workers, especially nurses, about the

importance of completeness in filling medical

records.

4. For the hospital to provide work motivation to

the nurses in the treatment room about the

importance of the completeness of medical

record files

5. For further researcher need to dig further

information related to medical record

completeness by taking all indicator in filling

in the medical record of inpatient (for example

identity, anamnesis, investigation etc) so that

can get good analysis result

REFERENCES

Great, Private. Analysis of Influence Factor Knowledge,

Motivation, and Perception Nurses About Room Head

Supervision Against the Implementation of Nursing

Care Documentation in Inpatient Room of Kelet

Hospital. Central Java Province in Jepara. Semarang:

Faculty of Public Health. UNDIP; 2009

Ardika. Relationship between Nurses' Knowledge of

Medical Records with Completeness of Nursing

Records. Semarang: Diponegoro University

Semarang. 2012

Dewi, Sartika. Physical examination.

http://nursingbegin.com/tag/pemeriksaan-

phisik/(online) accessed 07 February. 2018. Jakarta.

2010

Gondodiputro. Medical Records And Health Information

System In Primary Health Care Facilities Puskesmas.

E-Journal of Public Health Sciences Faculty of

Medicine, Padjadjaran University of Bandung. 2007

Notoatmodjo. Health Research Methodology. Jakarta:

Rineka Cipta. 2010

Permenkes No. 269 / Menkes / Per / III / 2008. About

Medical Record. Jakarta: 2008

Shofari B. Management of Medical Record Service System

at the Hospital. Jakarta: Rineka Cipta.2006

Utami, Sri. Knowledge Level Relationships About Medical

Records With Completed Filling Of Nursing Notes On

Inpatient Installations At At-Turots Hospital Al Islamy

Sleman. Yogyakarta. E-journal. Retrieved on February

2, 2018. http://www.permataindonesia.ac.id/wp-

content/uploads/2016/08/06. -Journal-PI_Utami-

Amalina-Fahmi.pdf. Journal of Permata Indonesia.

Volume 7, Number 1, May 2016. 2016.

ICRI 2018 - International Conference Recent Innovation

498