Relationship of Nurse's Knowledge Concerning Medical Recording With Nursing Care Document Completeness

Abstract

Background: Completeness of medical records is a medical record that is completely filled out by a doctor within ≤ 24 hours of completion of outpatient services or after an inpatient is decided to go home.Methods: This type of research is descriptive. The data were collected using a questionnaire and direct observation. The data were processed by editing, coding, processing, and cleaning, which were analyzed using computerization.Results: The results showed that less than half (46.7%) of the medical record files were incomplete and 33.3% had low knowledge of nurses.Conclusions: The conclusion in this study was that less than half (46.7%) of nurses did not complete medical record files and it was found that nurses lack of knowledge in filling out nursing care documents completely. It is better if reward should be done for nursing care documents.