The behavior of specialist towards completeness of medical records

This study aims to overview and identify how medical record is executed by specialists in undertaking their medical tasks. This study involves specialists at Dr. M. Soewandhie hospital. Based on the preliminary research, one of the problems in paper-based medical record is the incompleteness of medical record filling. The incompleteness is mostly caused by the specialists-in-charge who had not filled the form. Due to this, this study formulized a research problem on factors that influenced the compliance of specialist in completing the filling of paper-based medical records. This study applied a cross-sectional study with a descriptive analytic design. This study was conducted in patient units with the total of respondents of 35 full-time specialists along with 175 medical record files used as research data. This study resulted from 175 medical records, there are 97.1% completed medical records, and 0.029% incomplete medical records. It indirectly indicated a breach of specialist's duty to maintain complete medical records. This study concluded that voluntary and obligation factors were the two factors that affected the specialist to fill-in medical records completely, and it was tested by the regression test. Rather than out of a sense of responsibility, the medical records were actually the authority of the hospital director and monitoring-evaluation manager who has authority and high order for specialists to complete medical records.