The

ole of Leadership Improves the Doctor's Performance in

Completing Medical Records

Lily Widjaja

, Laela Indawati

, Nanda Aula Rumana

and Muniroh

Medical Record and Health Information Study Program, Faculty of Health Sciences, Esa Unggul University

Keywords: Job satisfaction, leadership, medical record

Abstract: Hospitals must have leaders who are obeyed and respected by their subordinates. Hospital leaders determine

goals,motivations and actions for doctors who provide care and complete patient medical records.

Complete, accurate and timely medical records (MRs) need to be done fully in improving services. The

implementation of MR documentation audits is carried out as part of internal supervision which

recommends incompleteness problems that will have a negative impact on hospital performance. Based on

preliminary observations at Adjidarmo hospital, the completeness of inpatient medical records, especially

on the doctor's note sheet, began at the ED or Clinic. Preliminary studies related to history on the patient's

physical examination, development notes and summary were still incomplete. This phenomenon shows that

the performance of doctors in filling medical records is still low, allegedly caused by factors of satisfaction

with leadership style. The purpose of this study was to analyze the Satisfaction Factors of leadership that

affect the performance of filling in MR in Adjidarmo Hospital. The research hypothesis is that there are

influences of leadership satisfaction factors on the performance of filling medical records. This type of

research is carried out with the quantitative analytical description method and uses a cross-sectional

approach. This research design uses descriptive design and causal design. The population is 74 people,

accidental sampling is 36 people. The independent variable is the factor of physician satisfaction in

leadership and as the dependent variable is Medical Record Filling Performance. Research instruments are

working a questionnaire form. Research analysis using simple linear regression. The normality test is done

through, Kolmogorov-Smirnov with normal distributed data Regression Coefficient Test Results that

independent variables with dimensions of satisfaction on leadership significantly influence the completeness

of MR.

1 INTRODUCTION

Medical Records (RM) is a source of data that is

processed and presented into medical information in

health care institutions. Medical Records should

contain medical and administrative data that

describe in detail all aspects of patient care that

occur either manually made on paper / electronic

forms or sheets using a computer. A complete and

accurate medical record is a reflection of the quality

of care provided.

Opinion by Nurman in HuffPost (7/03/2018

05:46 am ET) that “‘Minor’ Errors In Medical

Records Can Have Major Consequences”. Quality”

is a buzzword in many industries ― but in health

care, it is lumped in with “safety,” since poor quality

can lead to much more than just customer

dissatisfaction.

Medical errors are the third leading cause of

death in the U.S., according to Johns Hopkins

University School of Medicine researchers: Each

year, approximately 250,000 patients in the U.S. die

due to such errors. However, more often than not,

medical errors hurt patients in unobvious ways, just

as an illness does not always present itself clearly

and instead takes root perniciously, over time and

under the radar. They are a sign of a much more

severe ailment that plagues our entire health care

system.

One place these errors lurk is in documentation

and medical records.Writing of diagnose during on

appointment the "anorexia" should be "anorexic"

the medical term for loss of appetite, while

“anorexia nervosa” would have been a diagnosis in

and of itself - a complex mental illness, in

fact,Limas (2012) in his research proves that

Widjaja, L., Indawati, L., Aula Rumana, N. and Muniroh, .

The Role of Leadership Improves the Doctor’s Performance in Completing Medical Records.

DOI: 10.5220/0009953528432848

In Proceedings of the 1st International Conference on Recent Innovations (ICRI 2018), pages 2843-2848

ISBN: 978-989-758-458-9

2843

physician busyness is one of the factors that

influence the completeness of medical records.

Akbar (2012) states that there is a relationship

between physician years of service with the

completeness of filling in medical record data at

Kerawang Primary Health Care. While Rosalina

(2013) in her research at 3 hospitals proved that

satisfaction in work, compensation, leadership, co-

workers and promotion proved to have a significant

effect on the performance of doctors in filling out

medical records of patients. The results of Hari

Purwanto's research (2015) found that job

satisfaction factors consisting of work,

compensation, promotion, supervision, co-workers

and working conditions influenced the performance

of employees in Madiun City 1 Junior High School.

Lihawa (2015) in his research stated show that a

relationship between the unsystematic composition

of the medical record form and incomplete filling of

medical records. A solutionto improve the

completeness of medical records is to create an

integrated medical record draft form.

Pahmi (2011) in his research stated show that

leadership style and job satisfaction have a positive

and significant effect directly on employee

performance

The purpose of the study to analyze the effect of

job satisfaction on completeness of filling the

medical record.

2 LITERATURE REVIEW

2.1 Leadership (Supervision)

According to Hasibuan (2010: 170) leadership is the

way a leader influences subordinate behavior, in

order to be willing to work together and work

productively to achieve organizational goals.

According to Jhon Kotter (Robbins and Judge, 2007:

356) leadership is about dealing with change.

Leaders set the direction by developing a vision of

the future so that they align people by

communicating this vision and inspiring them to

overcome obstacles. Greenberg and Baron (2008:

501) define leaders as someone in a group or

organization that has the greatest influence on its

members, and they define leadership as a process by

which a person influences group members to achieve

organizational or group goals.

2.2 Completeness of Medical Records

According to Ruthann Russo (2013), good Medical

Record Documentation (MR) includes activities that

ensure quality data and information. Clinical

documentation in MR patients is strictly regulated.

Clinical documentation is the main meaning that

doctors or nurses use it to communicate about their

opinions about the patient's condition and the

decision on how to treat the patient. Koder used

Clinical Documentation in the processing of clinical

data by determining the diagnosis code and actions

on MR patients. Clinical Documentation was the

basis for coding by using the International Statistical

Classification of Diseases and Health Related

Problems edition 10 (ICD-10) and coding the actions

using books. "International Statistical and

Classification of Diseases and others related

problems, Ninth Edition, Clinical Modification"

(ICD-9CM).

 Improving the quality of Clinical

Documentation (Clinical Documentation

Improvement = CDI) aims to ensure that doctors

provide the most complete, clear, reliable, timely,

readable and accurate information/documentation

that is consistent with clinical findings (examination

results) in Medical Records. The CDI program

includes reviewing medical records of patients who

are still being treated who, by immediately

identifying an increase in clinical documentation.

Based on Permenkes 269, (2008), article 2 paragraph

1 states that "Medical Records must be made in

writing, complete and clear or electronically.

Completeness of Medical Records can be done in

several ways: In America, the Department of Health

and Human Services (HHS) section of the Office

Inspector General (OIG) recommends minimum

completeness instructions for RM documentation:

MR is complete and readable.

 Listed past and present diagnoses in MRRK

 Identify the Health Risk factors appropriately

 There is a reason to request a diagnostic and

other supporting examination

 Document the patient's development and

reaction to treatment changes and other

revisions of diagnosis.

 Documentation at entry must have reasons to

be treated with relevant history, findings from

physical examinations, results of preliminary

examinations, assessments, clinical image,

diagnosis, care plans, care dates and identities

of service providers that can be read.

ICRI 2018 - International Conference Recent Innovation

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2.3 Quantitative Analysis

Also called Discharge Analysis: reviewing the

completeness and accuracy of Health Records.

Generally done in a Retrospective Analysis when the

patient has been discharged from the hospital. It can

also be done by Concurrent Analysis when the

patient is still being treated.Things to note:

 The first time RM arrangement was made so

that the RM sheet that was lacking could be

immediately known,

 Then see author authentication in the form of

the author's signature,

 Good writing; if there is an error crossed one

line and initialed, given the date of correction

then write down the improvement.

 Timely and readable, using standardized

abbreviations

 Accurate and complete

Quantitative analysis includes a review of RK

completeness based on regulations, accreditation,

licensing and billing requirements that apply in both

paper and electronic RK-based hospitals.

Hatta (2008) Quantitative Analysis is reviewing

certain parts of the contents of the RM with the

intention of finding deficiencies, especially those

relating to RM documentation.

Writing / documenting this Medical Record is

regulated by the Head of the Medical Record /

Health Information section together with the

relevant health service provider.

3 RESEARCH METHOD

Types And Designs of The research

wasconducted using quantitative analytical

description method and usingcross-sectional

approach. This research design uses descriptive

design and causal design, described as follows: 1.

Descriptive design: the exposure is intended to

describe the things that are asked in research as:

what, who, when, where, why and how a topic of the

problem. In this design more on the data collection

and decomposition thoroughly and thoroughly

according to the issues discussed.

The data of medical record filling performance is

obtained from the result of a field survey conducted

by the researcher in Medical Record unit, and

independent variable from the respondents that have

been determined in RS Adjidarmo

2. Causal design: to know the causal variables

(independent variables) and the variables that result

(dependent variable) and analyze the relationship

between variables or how a variable affects other

variables. Further data is processed statistically

using SPSS version 22.0 for windows.

The population of this study are general

practitioners and specialist doctors in the inpatient

room with a total of 74 people. Sampling technique

with accidental sampling obtained as many as 36

people

Variables This study consists of independent

and bound variables;Independent variable;

consisting of satisfaction of leadership, and as the

dependent variable is the completeness of the filling

of Medical Record based on 4 components of

quantitative audit of documenting the Medical

Record, ie, the completeness of patient identity, the

completeness of the important report, the

completeness of Authentication writer, and good

Recording

The instrument used to collect data related to

leadership factors on Medical Record Filling

Performance is a

4 RESEARCH METHODOLOGY

Research on the development of thismedical record

module prototype is a type of applied research. The result

of this research can be directly applied to solve the

problems faced

.([MOE 2012], 15)

This research will apply Agile development model

using SCRUM system development method which was

documented by collecting all BackLog (User Needs) to be

made into small modules to determine the priorities to be

lateranalyzed and formed into a basic foundation to build a

continuously developing Medical Record Module to

accommodate hospital needs. The results of each analysis

will later be made into a medical record application

module using the PHP

programming language and

SQLSERVER database, then the application was tested

based on the functions required by the user before being

demonstrated to the end user.

Questionnaires will be

tested for validity and reliability. Methods of data

collection by distributing questionnaires that have

been reliable to medical record recharge

practitioners, in this case, the inpatient doctors. The

validity test in this research uses the formula

"product moment" (r) and reliability test using Alpha

Cronbach's test.

For Hypothesis: examine the effect of

leadership satisfaction on Medical Record Filling

Performance using simple linear regression with

models:

a. Ŷ = a

+ b

Ŷ = dependent variable (Medical Record Filling

Performance)

The Role of Leadership Improves the Doctor’s Performance in Completing Medical Records

2845

X2 = independent variable (satisfaction with

(leadership)

= constant (intercept)

= regression coefficient

if b

= 0: X

does not affect Y: satisfaction with

the leader does not affect the Performance of

Medical Record Filling

Ha if b

≠ 0: X

affects Y: satisfaction with the

leader influences the Performance of Medical

Record Filling.

5 RESULT DATA

5.1 Simple Regression Analysis Results

From the overall indicators asked by respondents

regarding personal data, it can be concluded that:

 Age Group

The highest age group is the age group 31-40

years (52.8%), and at least the age group> 40th.

(27.8%)

 Gender

Male respondents (55.6% more than women

(44.4%).

 Final Education

Respondents with the latest education, The

general practitioner is higher (60%) than the

specialist doctor (40%).

 Long Working

The largest group of respondents was the group

that worked 2-5 years as many as 22 people (61.1%).

Validity and Reliability Test Results

The purpose of this validity and reliability test is

to find out whether the raw data taken in the field is

valid and reliable or not. The instrument has been

tested on 23 respondents and then tested the validity

and reliability based on SPSS 22.00 output. The

correlation used is Pearson Product Moment

correlation with alpha 5% (α = 0.05).

Table 1:Test Validity and Reliability Satisfaction with

Leadership

No.

Instru

ment

items

Standa

rdizati

on of

validit

y tests

Valid

ity

Test

Resul

Val

Stand

ard

reliab

ility

test

Cron

bach'

Alph

Rel

iab

ilit

Questi

on 1

0.352

.693

+ 0.6

.911

Questi

on 2

0.352

.804

+ 0.6

.887

Questi 0.352

.771

+ 0.6

.893

on 3

Questi

on 4

0.352

.783

+ 0.6

.890

Questi

on 5

0.352

.866

+ 0.6

.873

Source: Result from SPSS 22.00, 2017

From the table above the results of the validity

test, all items question satisfaction with Leadership

valid because the validation value is 0.352. Test

Results Reliability of all items of satisfaction with

Leadership is declared reliable because the

reliability value is ≥ 0.6≥ 0.352. Test Results

Reliability of all items of satisfaction with

Leadership is declared reliable, because of its

reliability value ≥ 0.6

5.2 Classic Assumption Test for

Normality

To conduct a test for normality is carried out

through, Kolmogorov-Smirnov.The basis for

decision making is based on probability.

If the probability value is>0.05, then Ho is accepted

If the probability value is <= 0.05, Ho is rejected

Table 2: Testnormality used Kolmogorov-Smirnov

Sta

istic df Si

Leadershi

.11

36 .200

So from the results of Kolmogorov-Smirnov

above the following: independent variables

related:leadership satisfaction = 0.200 which means

≥ 0.05, the population is normally distributed

Table3: The results of a simple regression analysis

Variable B Beta p-value

value

P value

Result of

Submission

X 0,282 0,349 0,019 12,25 0,000

Rejected

Constants

4,5

0,018

Regression coefficient variable of leadership

satisfaction is 0.349; that is, if another independent

variable has a fixed value and Leadership

Satisfaction has a 1% increase, then "completeness

of medical record" will increase by 0.349

times.There is a significant effect of leadership

ICRI 2018 - International Conference Recent Innovation

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variables on completeness variables at p = 0.019

(<0.05).

6 DISCUSSION

Satisfaction with leadershiphas a partial effect on

medical record completeness at p-value = 0,019 If

the variable of satisfaction toward leadership has 1%

increase, while another variable is assumed to be

fixed, it will cause an increase of 0.282. The

coefficient value shows that the satisfaction of

leadership has a positive effect on the completeness

of the medical record. This illustrates when good

leadership, then the employee/doctor will be

satisfied, and impact on the completeness of medical

records. This is in line with the proposed Armstrong

(2003) states leadership is the process of inspiring

all employees to work as well as possible to achieve

the expected results. Leadership is a way of getting

employees to act right, reaching commitment and

motivating them to achieve common goals

According to Hasibuan (2010: 170) leadership is

the way a leader influences subordinate behavior, in

order to be willing to work together and work

productively to achieve organizational goals.

Leadership is a process by which a person influences

group members to achieve organizational or group

goals. Pahmi (2011) leadership style and job

satisfaction affect on positive and significant directly

to organizational commitment. Leadership style and

job satisfaction affect positive and significant

directly to officer performance. Moreover, also there

is an influence of significant indirectly between

leadership style and job satisfaction to officer

performance through organizational commitment.

From the results of Misriani Niel's research

(2013), it was found that the degree of relationship

between leadership style and work motivation of

employees at the Makassar City Transportation

Agency can be quantitatively very high or the

relationship is very strong.It can be said that an

effective leadership style is a leadership style that

suits the situation faced in this case not only one

leadership style that must be applied, but must be

adapted to the situation and conditions that occur or

according to the needs of the company, so that it can

affect the increase in employee motivation. The

success of leaders with leadership styles that are in

accordance with the situation and conditions affect

the satisfaction of inpatient doctors in Adjidarmo

Hospital, increasing their work motivation which

can be reflected in their performance in completing

Medical Records.The existence of an appreciation of

achievement and an increase in functional positions

in addition to structural positions at the hospital

affected doctors in pursuing their careers.

7 CONCLUSION

The conclusions in this study thatvariable that

affect the completeness of medical record is the

satisfaction toward leadership. In the participatory

leadership style, there needs to be an increase in the

indicators of treating employees equally. This

increase can be developed by providing fair role

models without favoritism towards employees.

Other research needs to be done to find out other

variables that affect the completeness of medical

records.

The complete medical record will give effect to

those who use medical records. Whether for

institutions, service providers, patients or third

parties will also feel satisfied because their needs

can be met, both for the continuity of medical

services, the importance of billing service fees,

education, research, can also be used as legal

evidence in court.

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