Every hospital is required to maintain medical records. In the medical record there is a medical resume form which is very important to complete, because it contains the entire medical history of the patient. Problems were still found related to filling out incomplete medical resume forms at Batu Bara General Hospital.The purpose of this study was to determine the factors related to the completeness of inpatients medical resume at Batu Bara General Hospital. This type of research used an observational research method by using cross sectional design. The total population were 36 doctors who work at Batu Bara General Hospital.The sampling technique used total sampling. The research instrument was questionnaire and checklist sheet. Data analysis used Chi Square test. The results showed that from 36 doctors, 23 doctors (64%) had knowledge in the good category about filling out medical resume sheets and 13 doctors (36%) had knowledge in the poor category while 27 doctors (75%) had attitudes in the good category. and 9 doctors (25%) had bad attitude.The results of Chi Square test showed that there was significant relationship between doctor's knowledge and the completeness of a medical resume with P value of (0.003) (P-value <0.05) and Prevalence Ratio (PR) = 0.081. Meanwhile, the results of the Chi Square test showed that there was a significant relationship between the attitude of doctor and completeness of medical resume with P value (0.021) (P-value <0.05) and Prevalence Ratio (PR) = 0.200. The hospital should provide understanding and socialization to doctors that it is important to complete medical records, especially on medical resume sheets
Perkembangan zaman telah menjadikan kebutuhan semakin kompleks. Kebutuhan akan kemudahan dalam mengakses teknologi mengharuskan suatu perusahaan untuk meningkatkan kinerjanya demi memenuhi faktor kepuasan pelanggan Pentingnya penggunaan teknologi informasi mulai disadari oleh organisasi modern, terutama dalam era globalisasi dimana perusahaan/instansi dituntut untuk semakin kompetitif dan berdaya saing. Oleh karena itu menjadi penting untuk memacu tingkat pemanfaatan dan penggunaan teknologi informasi di organisasi. Manfaat penggunaan Rekam Medis Elektronik (RME) telah diakui secara luas. Salah satu manfaatnya adalah pemeriksaan data yang berkelanjutan berkualitas, terutama ketika pembuatan dan pengumpulan data dilakukan secara otomatis. Misalnya data dari perangkat laboratorium, atau dari radiologi. Manfaat lain kemampuan penyimpanan data dalam jumlah besar dalam waktu komputasi singkat, menghasilkan hasil yang handal. Tujuan dari pemanfaatan RME sebagai solusi berbasis Informasi Teknologi (IT) yang dapat meningkatkan pertukaran informasi dan komunikasi antar tenaga kesehatan yang lebih efektif karena data saling terintegrasi. Metode penyuluhan dilakukan menggunakan peresentasi dan interaksi kepada pegawai di Rumah Sakit Umum Cut Meutia Kabupaten Aceh Utara. Kesimpulan akhir dari kegiatan pengabdian masyarakat ini adalah dari kegiatan penyuluhan pegawai dapat mempermudahkan pekerjaanya dengan pemanfaatan rekam medis elektronik di instalasi rawat jalan rumah sakit
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