The Importance of Nurse Knowledge about Physical Examination and Inform on Medical Record Facility Inpatient Patient: Case Study in Sari Asih Hospital Karawaci Tangerang Astri Annatasia1, M. Reza Hilmy1, Rokiah Kusumapradja1 and Erlina Puspitaloka Mahadewi2 1Master Program Adminsitrasi Hospital (S2, Esa Unggul University Jakarta 2Faculty of Health Sciences, Esa Unggul University Jakarta Keywords: medical records, knowledge, inpatients. Abstract: Based on the results of the observation in Sari Asih Hospital Karawaci Tangerang obtained medical record of hospitalized records are still many empty is that in 2016 there are 296 (3.4%) patients and in 2017 there are 405 (3.9%) patients. The incompleteness of medical record data mostly occurred on the accuracy of patient identity (name, a medical record number, place of birth date, sex) that is 37 patients (9%); and physical examination of 44 patients (11%), informed consent 47 (12%). The nurse's function as one of the data inputs that make the documentation of nursing care actions will affect the quality of the patient's medical records. The incompleteness of DRM is because there are still many nurses who have poor knowledge (60%) about medical records.The purpose of this research is to determine the effect of knowledge of nurses in filling out medical records on the completeness of medical records file of inpatients (case study in Rs. Sari Asih Karawaci Tangerang). The design of this study is associative causal (causal) with a quantitative approach. The object of this research is nurses in hospital wards as much,and samples counted 25 people with purposive sampling technique. Data collection by using primary data in the form of questionnaire/questionnaire and secondary data based on RM 2017 data which then analyzed by binary logistic regression analysis.Based on the result of regression logistic binary statistical analysis, it is found that the nurses' knowledge variable in the filling of the medical record has a significant effect on the accuracy of the medical records file of the inpatients The better the nurse's knowledge,the more complete the patient's medical record. Advice for hospitals to socialize, regularly monitor and evaluatenurses, about the importance of completeness in filling the medical record. 1 BACKGROUND There is already a fixed procedure (attached) about the completeness of medical records data in Hospitals are health referrals that serve inpatient turned out from the observations in "RS outpatients, emergency and inpatient care with Sari Asih Tangerang" in the assembling in the various types of medical services and medical implementation of his duties generated data medical support in a hospital service system. Serving the records hospitalized records are still many empty. patient is one of the hospital services, in accordance RS Data. Sari Asih Karawaci Tangerang in 2016 with the Regulation of Medical Record (RM) in showed 8,793 (14.7%) of inpatients from 59,993 accordance with the Regulation of the Minister of patients overall, from 8,793 inpatients there were Health of the Republic of Indonesia Number 269 / 296 (3.4%) patients with incomplete medical record Menkes / PER / III / 2008 dated 02 March 2008 on data. While in 2017 it showed an increase in Medical Record. Also described medical record is a hospitalized patients to 10,308 out of 85,947 patients file containing records and documents about the as a whole, and from 10,308 inpatients there were patient's identity, treatment examinations, actions 405 (3.9%) patients with incomplete medical record and other services that have been given to the data. The incompleteness of medical record data patient. Medical records should be in writing, mostly occurred in the patient accuracy of patient complete and clear or electronically. identity (name, a medical record number, place of birth date, sex) that is 37 patients (9%); and physical 491 Annatasia, A., Hilmy, M., Kusumapradja, R. and Puspitaloka Mahadewi, E. The Importance of Nurse Knowledge about Physical Examination and Inform on Medical Record Facility Inpatient Patient: Case Study in Sari Asih Hospital Karawaci Tangerang. DOI: 10.5220/0009950704910498 In Proceedings of the 1st International Conference on Recent Innovations (ICRI 2018), pages 491-498 ISBN: 978-989-758-458-9 Copyright c 2020 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved ICRI 2018 - International Conference Recent Innovation examination 44 patients (11%), informed consent 47 medical record file and Understanding the correct (12%) way of writing medical records file in accordance The nurse's function as input data made from the with Permenkes year 2008 with instrument is a nursing care actions performed will affect the poor questionnaire consisting of 15 items of questions quality of information in the patient's medical with interval scale records. Better health data quality in the patient's medical record can be reviewed by and therefore 2.1 Research Result requires a good knowledge of the nurse. Knowledge of medical records, in this case, is The result of research is shown in the frequency the knowledge of what should be accomplished in distribution of respondent characteristics as follows: the filling example of medical records other than that how to create a medical record correctly in Table 1: Characteristics of Nurse RS Sari Asih Karawaci accordance withPermenkes (2008) consisting of Tangerang patient identification, treatment examinations, No Characteristics of Amount % actions and other services that have been given to Respondents the patient 1. Age Initial survey conducted by the researchers 20-26 years old 6 24 resulted in data that there are still many nurses who 27-40 years old 15 60 have poor knowledge (60%) about the medical 41-61 years old 4 16 record. 2. Last education The existence of this study is expected to SPK 0 0 contribute or its application, especially for nurses DIII 13 52 about the filling of medical records S1 8 32 This motivation is to improve the knowledge S2 4 16 about the medical record so that the quality of 3. Years Of Work medical record becomes better and better quality. < 1 year 2 8 < 5 year 5 20 < 10 year 10 40 > 10 year 8 32 2 RESEARCH METHODS 4. Gender Man 7 28 This research method using research method Woman 18 72 with a quantitative approach to know the significant Source: data that has been processed (2018) relationship between variables studied. The Based on Table 4.1 above, respondents are technique used in this study is to determine the mostly aged 27-40 years, 60%, most respondents sample size of the population is a purposive have recent education DIII (52%), work-based sampling technique. Data analysis used binary characteristics are mostly found <10 years (40%) logistic regression analysis. Sari Asih Karawaci and most of them are female (72%). Tangerang with one shot time horizon to study that is research done with the previous study, week, 2.2 Variable Descriptive Satistics week, in order to answer the research question Table 2: Results Descriptive Statistics Variable OPERATIONAL DEFINITIONS VARIABLES Variabe N Mini Ma Mean Std In this study the dependent variable (Y) is the l mum xim Deviation um completeness of the medical record is a file Knowle 25 6 15 11.40 2.90115 containing records and documents about the identity, dge examination, treatment, action, and other services Complet 25 32 37 36.12 1.56312 that have been given to the patient in the form of e Medical physical examination data and informed consent Record with the instrument of the questionnaire based on Vallid 25 medical records of RS Sari Asih Tangerang in 2017 (N) with interval scale. While the independent variable Source: data that has been processed, SPSS 24 (X) is the knowledge of the nurse that is knowledge about what should be completed in the filling of 492 The Importance of Nurse Knowledge about Physical Examination and Inform on Medical Record Facility Inpatient Patient: Case Study in Sari Asih Hospital Karawaci Tangerang Output table 4.2 above shows the value of N or Table 4: Reliability Test the amount of data to be studied amounted to 25 Variable Cronbach’s Conclusion samples. The nurse's knowledge about the filling of Alpha medical record file has mean or a mean value of Nurse Knowledge 0.975 Reliable 11.40 which means that the average knowledge of About Medical the nurses is included in either category with a Record maximum value of 15 and a minimum value of 6 Source: Primary data that is processed (2018) With a standard deviation of 2.90115 it can be said the average value of deviation of knowledge In table 4.4 it can be seen that the knowledge variables is 2.9%. Furthermore, for medical record variable of medical record file has Cronbach's Alpha completeness variable obtained mean or mean value (α) above 0.60 so it can be said that all the concepts of 36.12 which means the average completeness of of variable measuring of the questionnaire are medical records file included in the category either reliable which means that the questionnaire used in with a maximum value of 37 and a minimum value this study is a reliable questionnaire to be analyzed of 32. With the standard deviation 1.56312 can be Furthermore. said the average value of deviation variable the completeness of the medical record is 1.56%. 1. Wald Test The descriptive results of each variable based on Table 5: Wald Test Wald df Sig. conclusion the number of presentations are as follows : Step 1a Medical 11.000 1 .006 Be Record accepted StatisticsTest Completen 1. ValidityTest:The test results of instrument ess validity to 10 respondents are as follows: Constant 1.199 1 .000 Table 3: Validity Test Results Source: Primary data that is processed (2018) Based on table 4.5 above can be seen that the value of wald by 11,000 with the value of sig 0.000 <0.05 (5%), it can be concluded that the hypothesis accepted the knowledge variable significantly affect the completeness of the medical record file.