Analysis of Electronic Medical Record Completeness in Relation to Quality at R. Moh. Noh Nur Regional General Hospital (RSUD)

One of the quality control activities in the management of Electronic Medical Records (EMR) is the assembling process, which aims to ensure the completeness, accuracy, and consistency of medical record data before it is used for clinical services or reporting purposes. This study aims to assess the quality of services in supporting the completeness of Electronic Medical Records at R. Moh. Noh Nur Regional General Hospital (RSUD). The study employs a quantitative approach with a descriptive design. Data collection was conducted through observation using an EMR completeness checklist. The results indicated that out of 31,283 inpatient EMRs audited during the assembling process, 28,757 documents (92%) were found to be complete, while 2,526 documents (8%) were incomplete. Incomplete entries in Electronic Medical Records can negatively impact the quality of healthcare services, administrative processes, and the quality of information generated by the hospital. Enhanced monitoring, evaluation, and coordination between medical records staff and healthcare professionals are necessary to minimize EMR incompleteness. Quality service provision helps identify incomplete data entries and ensures the availability of health information that is complete, accurate, and accountable.