Identification of the Fulfilment of Medical Record Incompleteness in the Inpatient of Muhammadiyah Hospital Lamongan

The fulfillment completeness of medical record in Muhammadiyah hospital is very poor. The study aimedto identify the precaution of incompleteness fulfillment of medical record in the inpatient of Muhammadiyahhospital lamongan. This was a descriptive study with observational and cross sectional design. The populationwas all file of inpatient medical record. Observations were hold in 94 medical record files of 7 inpatient rooms.Thisstudy include interview with the officer of medical record to complete the result of this study. The result of thestudy showed that the fulfilment completeness of medical record file had different performance. Standardoperating procedure; job description; reward and punishment regulating the medical record fulfillment were verygood. In other side, the evaluation of medical record filling process was also in very good category. Although,monitoring in filling process was not implemented. This study concluded that the determinant of inpatient medicalrecord fulfillment incompleteness in Muhammadiyah hospital is the failure of fulfilment monitoring. This studysuggests that should be more routine medical record filling process monitoring.Keywords: incompleteness, medical recor