This study is aimed to evaluate the performance of doctors in completing medical record in terms of the characteristics of the doctors. The type of this research is analytic research which is examined the relationship between characteristics the doctor, such as age, work period, knowledge of the medical record, gender, type of expertise, education and the employment status with the completeness of filling out the summary sheet (doctor's resume). The samples used 374 medical record documents and 7 doctors. The obtained data will be analyzed through Multiple Logistic Regression. The results of this study shows that the variables have a relationship with the completeness of filling out the Summary Sheet (Doctor's Resume) are the knowledge of the medical record, work period and medical education with a strong relationship category. While based on multivariate analysis, shows that these three variables also affect the completeness of filling out Summary Sheet (Doctor's Resume). Doctors who have knowledge of the medical record, work period >5 years and taking non specialist master's degree can fill the completeness of the medical record documents properly. The author gives advice to the General Hospital District dr. Soeratno Gemolong Sragen for holding training, education and medical record seminars to the doctors seminars to improve the completeness of the medical record documents.

Completeness of medical information is very important in supporting the accuracy of the diagnosis code for diabetes mellitus. This study aims to determine the relationship between the completeness of medical information and the accuracy of the diagnosis code for Diabetes mellitus in hospitalization documents. This research is an analytical study with a cross sectional approach. The sample used was 84 documents with simple random sampling technique. Data analysis using Chi-Square. The percentage of completeness of medical information was 54.7% while the incompleteness of medical information was 45.3%. The highest incompleteness is in the 26 discharge summary (31%). Percentage accuracy of diagnosis code Diabetes mellitus is 29.8% while inaccuracy is 70.2%. The most inaccuracies are caused by incorrect in determining the type of Diabetes mellitus as many as 24 documents. Chi square statistical test showed that p = 0.001. The conclusion is that there is a relationship between the completeness of medical information and the accuracy of the diagnosis code for Diabetes mellitus. The author suggests that there should be coordination between medical record officers and other health workers to improve the completeness of medical information, coding officers are more thorough in coding and confirming to physician if the information is incomplete.

<span>The accuracy of the diagnosis code has implications for future patient care planning, provision of health services and patient care costs. Therefore, <br /> this study has analyzed the influence of the quality of medical information on the quality of the diagnosis code which includes the accuracy, consistency, completeness and timeliness in coding the diagnosis of inpatients at <br /> Dr. Moewardi hospital.</span><span>This was an observational analytic study with <br /> a sample of 250 medical records taken using stratified random sampling. Data were analyzed by chi square test</span><span lang="IN">. </span><span>High quality of medical information has a better diagnosis code quality (73.80%) compared to poorly quality of medical information (36.00%). High quality of medical information has a log odds of 1.54 better in the quality of diagnosis code than poorly quality of medical information (b=1.54; 95% CI=0.81-2.27, p&lt;0.001).</span>

Background: Diagnosis coding is atool for identifying and grouping diseases, disorders, symptoms, and other disease-related outcomes, such as poisoning, adverse effect of drugs and chemicals, and injury. Diagnosis code can be used in policy making and costing medical care. Doctors, nurses, coding personnel, and medical record quality, may affect the quality of diagnosis coding.

Teknologi informasi berkembang sangat pesat, tidak terkecuali di bidang pelayanan kesehatan. Rekam Medis Elektronik merupakan salah satu faktor penting untuk meningkatkan kualitas dan keamanan layanan kesehatan, mengurangi kejadian buruk bagi pasien, mengurangi biaya, mengoptimalkan pelayanan, meningkatkan penelitian klinis, dan memperoleh luaran klinis yang lebih baik. Pengabdian kepada masyarakat ini bertujuan untuk mengimplementasikan sistem informasi rekam medis berbasis website untuk meningkatkan mutu pelayanan Kesehatan di klinik. Metode yang dilakukan dalam pengabdian kepada masyarakat di klinik ini yaitu penyediaan perangkat keras (hardware), implementasi perangkat lunak (software) berupa aplikasi pelayanan pendaftaran dan pengelolaan rekam medis berbasis website, serta pelatihan penggunaan aplikasi aplikasi pelayanan pendaftaran dan pengelolaan rekam medis berbasis website kepada petugas. Hasil kegiatan pengabdian kepada masyarakat ini yaitu rekam medis elektronok mampu mengurangi waktu tunggu pelayanan kepada pasien sehingga kepuasan pasien terhadap pelayanan di klinik meningkat. Pengetahuan dan penerimaan petugas kesehatan di klinik juga meningkat setelah mengikuti kegiatan pelatihan dan pendampingan, sehingga dapat menjamin keberlanjutan program ini.