The Relationship Between Completeness of Diagnosis and Completeness of External Reporting of Inpatient Morbidity at X Hospital Batam
Year: 2026
Type: article
Study design: Observational Study
Abstract: The completeness of inpatient diagnoses is crucial for generating external hospital reports like RL 4a and RL 5.3. This study aims to analyze the relationship between the completeness of diagnoses and the external reporting of inpatient morbidity at X Batam Hospital. This was a descriptive quantitative study using a cross-sectional approach. The sample consisted of 354 inpatient medical record files in the fourth trimester of 2024, taken using a purposive sampling method. Data was collected through checklists and interviews. From 354 medical record files obtained Percentage of completeness of inpatient diagnosis at Rs X Batam was 86.7% and incomplete was 13.3%. On the other hand, the completeness of external reporting RL 4a and RL 5.3 only reached 97.1% and incomplete was 2.9%. The factors causing incomplete diagnosis in external reporting of morbidity (predisposition) were the lack of training in filling out medical records and socialization of SOP for completeness of filling out medical records. It can be concluded that there is a significant relationship between the completeness of diagnosis and the completeness of external reporting RL 4a and RL 5.3.
Source: Medrec Journal
DOI: 10.54973/mj.v2i1.748
Institution: Universitas Awal Bros
Language: English
Subfield: Health Information Management
Field: Health Professions
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W7204837232