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VOL. 7, ISSUE 1 (2025)
Identification of incomplete medical record for outpatients service at dental hospital
Authors
Sheila Achlaqul Qarimah, Heru Suswojo, Sholihul Absor
Abstract
Health services rely on comprehensive medical
record documentation. At the dental hospital, incomplete medical records remain
prevalent. Statistics from 2024 indicate that medical records were, on average,
nearly 100% incomplete—far below the target of 100% completeness. Accordingly,
this study aims to determine the frequency of missing information in outpatient
medical records and the factors contributing to this issue. Using a
comprehensive sampling strategy based on direct observation and documentation
studies, 2162 electronic medical records were analysed quantitatively through a
cross-sectional approach in November 2024. The process involved data
collection, revision, and result presentation. The findings revealed that
identity elements were 99.85% complete, authentication was 57.21% complete, and
significant reports were 53.21% complete. Consequently, the electronic medical
records from the November 2024 outpatient installation at Dental Hospital were
not fully comprehensive. Since medical record completeness reflects hospital
performance in patient care, hospitals should emphasise assessment, socialisation,
and monitoring to improve medical record accuracy as a key measure of
healthcare quality.
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Pages:49-52
How to cite this article:
Sheila Achlaqul Qarimah, Heru Suswojo, Sholihul Absor "Identification of incomplete medical record for outpatients service at dental hospital". International Journal of Dental Sciences, Vol 7, Issue 1, 2025, Pages 49-52
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