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| Advisor(s) | SOLIKH, AKHMAD FATIKHUS | |
| Author(s) | NAJWA, SUCITA | |
| Issued Date | 2026 | |
| Abstract | This study aims to determine the extent to which medical records are completed in the Neonatal Intensive Care Unit (NICU) of the Aceh Government Maternal and Child Hospital (RSIA) in 2026, based on the Medical Record Incompleteness Form (KLPCM). Using a quantitative descriptive method, a research sample of 48 medical records of NICU inpatients from January through May 2026 was selected using simple random sampling from a total population of 94 records. Data were collected through observation of a checklist and analyzed using univariate analysis. The results showed that the completeness of the identification review reached 93.7% (45 complete records), with the most common omissions being the date of birth and gender. In the authentication review, the completeness rate was 85.4% (41 complete files). Meanwhile, in the documentation review, the completeness rate was 89.6% (43 complete files), with physical examinations and laboratory/ supporting tests showing 100% completeness, while medical history, diagnosis, treatment, and medical summaries still showed some incompleteness. Overall, the completion of medical records in the NICU at the Aceh Government Maternity and Children’s Hospital is already considered good but does not yet meet the optimal standard of 100%; therefore, it is recommended that periodic training be conducted, completeness checklists be implemented, and Standard Operating Procedures (SOPs) be enforced for all healthcare personnel. | 1 |
| Item Type | Skripsi | |
| Keywords | Rekam Medis (Medical Records), KLPCM (KLPCM), NICU (Neonatal Intensive Care Unit), Reviewe Identifikasi (Identification Review), Review Autentikasi (Authentication Review), Review Dokumentasi (Documentation Review) | 1 |
| Collection | Fakultas Kesehatan Masyarakat, D4-Manajemen Informasi Kesehatan | |
| Publisher | INSTITUT KESEHATAN DELI HUSADA DELI TUA | |
| Submitted Date | 19-10-2026 | |
| Updated Date | 19-10-2026 | |
| URI | No URI | |
| File |
25199093_sucitanajwa_skripsi_D4.pdf
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