Assessment of Medical Record Document Completeness in Inpatient Units Before and After STARKES Accreditation in a Private Hospital

The Hospital Minimum Service Standards include several key components, one of which is the vital management of medical records. Achieving 100% completeness in medical record documentation is a key indicator of success in the health sector, and it significantly influences the level of hospital accreditation. Therefore, this research aims to assess the completeness of medical record documents in inpatient units based on three essential forms, including Entry and Exit Summary, Clinical Notes, and Informed Consent. This assessment was carried out both before and after STARKES accreditation in a private hospital. The data used in this research include the complete recapitulation of medical record documents during two distinct periods, which were from October to December 2022 (before) and February to April 2023 (after accreditation). To achieve the aforementioned objective, a qualitative research methodology was employed, utilizing a descriptive method. Furthermore, the data collection process entailed the calculation of average data as well as conducting interviews to gain comprehensive insights. The data was meticulously processed using specialized software to determine the proportion of completeness and identify any differences before and after the accreditation. After analyzing the research data, the obtained results showed that the completeness of the three forms, both before and after STARKES accreditation, fell short of the prescribed standards. Strikingly the Paired Sample T-Test indicated that there was no statistically significant difference in the completeness of inpatient medical records during the two phenomena. As a result, it is imperative to emphasize the need for regular monitoring and evaluation of standard achievement, as well as the implementation of effective motivational strategies for officers responsible for ensuring the completeness of medical record documents.