Completeness and Legal Implications of Patient Medical Records at Hajj Regional General Hospital of Makassar

Abstract

Information on a patient’s health development can be obtained if the data contained in the medical record are filled out completely, accurately and consistently. This study aimed to analyze the completeness of medical records and the legal aspect of the use of medical records in health services. This research was carried out at Hajj General Hospital of Makassar. The study was conducted retrospectively with a qualitative approach through in-depth interviews, observation of medical record files and document review, as well as with a quantitative approach, from October to December 2020. 258 medical record files were reviewed, and informants included five implementing medical personnel and 10 implementing nurses, who were interviewed to examine opinions about the completeness and legality of ownership of medical record files. The results showed that there were still incomplete medical record files, and most medical record items were not filled out completely and consistently, which has legal implications in terms of the file owner and the contents of the medical record. For this reason, open communication is sought between all health workers.
 Keywords: completeness, legality, medical record