Quantitave Review of Inpatient Medical Resume with Descriptive Frequency Table (Case Study Batujai Health Center)

Abstract

Inpatient discharge summaries serve as essential documentation, providing a comprehensive overview of patient care up to discharge and forming the basis for healthcare financing claim verification. Proper management of medical records directly impacts the quality of healthcare services, particularly in primary health centers. The failure to achieve minimum service standards necessitates routine evaluations within health center management. This study aimed to analyze the completeness of inpatient medical resume documentation at Batujai Health Center using descriptive frequency tables. A descriptive quantitative case study design was employed on a sample of 114 medical discharge summaries, calculated using Slovin's formula from a total population of 160 inpatient records spanning July to October 2025. Descriptive statistical analysis revealed that the patient identification review component and the physician authentication both achieved a complete frequency distribution of 100%. In the good recording review component, compliance with error correction rules showed a high frequency rate of 99%. Conversely, the frequency table within the essential report components identifies significant incompleteness: the completion of supporting examination entries reaches only 38%, while nursing actions account for merely 52%. This incompleteness of clinical data poses a potential threat to the quality of health information, disrupts the continuity of care, and hinders the process of financial claim verification. The presentation of descriptive statistics through the frequency table successfully maps the areas of medical record components that do not meet the Minimum Service Standards (100%). These findings should serve as a foundation for management to conduct regular oversight and evaluation of medical record completion in order to enhance the quality of health services.