Factors influencing the completeness of medical record documentation by healthcare workers in the inpatient unit

Medical records are essential documents in healthcare services, serving as a means of communication among professionals, a basis for clinical decision-making, and legal evidence. However, incomplete medical record documentation remains a common issue in hospitals, including inpatient units. Such incompleteness may compromise service quality and patient safety. This study aimed to analyze the factors influencing the completeness of medical record documentation among healthcare workers in the inpatient unit of Ridhoka Salma Hospital Cikarang and to identify the most dominant factor. This study employed a quantitative analytic design with a cross-sectional approach. The population consisted of healthcare workers (physicians, nurses, and midwives) working in the inpatient unit. A total of 109 respondents were recruited using a total sampling technique. Data were collected using structured questionnaires and a review of medical records. Data analysis included univariate analysis, bivariate analysis using Chi-square tests, and multivariate analysis with logistic regression. The findings revealed that 65.1% of medical records were documented completely, while 34.9% were incomplete. Factors significantly associated with medical record completeness were knowledge (p = 0.002), workload (p = 0.014), and length of service (p = 0.031). Logistic regression analysis indicated that knowledge was the most dominant factor influencing medical record completeness, with an OR = 6.21 (95% CI: 2.03–18.94). The completeness of medical record documentation among healthcare workers in the inpatient unit remains suboptimal. Knowledge, workload, and length of service were found to significantly affect completeness, with knowledge being the dominant factor. Hospitals should enhance healthcare workers’ capacity through routine training, manage workload proportionally, and strengthen supervision to improve medical record completeness.