The Relationship of Patient Education Documentation Compliance in Medical Records as an Indicator of Service Quality in Hospitalization of the X County Hospital

Abstract

The quality of hospital services is highly dependent on the achievement of patient safety and professional accountability of medical personnel, where systematically documented patient education plays an important role. This study aims to assess the level of compliance of health workers in filling out patient education forms and evaluate the operational role of Medical Recorders and Health Information (PMIK) in strengthening the quality of documentation at Hospital X Sumedang Regency. A descriptive observational approach was used with a three-month observation period in three inpatient rooms (Sakura, Tanjung, and Kenanga). Internal audits are conducted to record the percentage of compliance with filling out educational forms, with PMIK playing an active role in verification and monitoring using electronic systems. The results showed that the Sakura and Tanjung spaces managed to maintain the trend of increasing documentation compliance, reflecting the effectiveness of the quality management system and the commitment of the PPA. This high compliance is in line with improving the quality of service and patient safety, according to the findings of Anugrahsari (2021) and Faluzi et al. (2018). On the other hand, the Kenanga space experienced a significant decline at the end of the period, allegedly due to a high workload, low understanding of documentation, and a lack of routine supervision. Thus, this study recommends that RS X extend internal audits to all rooms; improve direct supervision by the head of the room with regular evaluation and feedback; carry out ongoing training on educational documentation; and implementing a digital reminder and monitoring system to ensure timely filling of forms. It is hoped that with the support of more operational PMIK and these measures, RS X can improve the consistency of educational documentation, service quality, and optimal fulfillment of patient safety standards.