Abstract

Medical records are important notes that reflect any information regarding patients while at a health care facility. Completeness of medical record is very important and should be implemented properly and correctly. The purpose of this study is to know the description of the causes of incompleteness of medical records of normal labor case at UPT Puskesmas Margorejo Kabupaten Pati. Type of research is narrative descriptive survey. This research is a mix method research with cross sectional study design. Methods of data collection by observation, documentation study, and interview. The sampling technique using saturated sampling, taking all the medical records of normal delivery cases not referred to in the third quarter of 2017 amounted to 46 documents. Result of research percentage incompleteness of identification review 57.2%, report review 6%, authentication review 22% and recording review 18%. The cause of incompleteness is caused by several factors, among others from the man or human resources aspect that is the age causing the officer's inaccuracy regarding the way documenting the medical record; the officer has never received training on fill out the normal labor medical records; the absence of officers with medical record educational background; and limited manpower. The cause of incompleteness of the methods aspect is the absence of Standard Operating Procedures (SPO) of medical record fullfillment in the delivery room. Suggestions from the researcher are the officer or midwife assistant delivery should be given seminar, training and workshop of fill out normal medical record to improve the skill of officer in documented medical record and need to make standard of operational procedure (SPO) fullfillment of medical record of normal childbirth as officer guide in recording medical record.