Studi Kelengkapan Dokumentasi Laporan Anestesi di Rumah Sakit Tk III 04.06.01 Wijayakusuma

Abstrak

Background: The completeness of anaesthesia documentation serves as a critical indicator of service quality and patient safety. Incomplete records can hinder its planning and clinical evaluation, while also posing potential legal risks. Objective: This study aims to evaluate the documentation completion rates across the pre-anaesthetic, intra-anaesthetic, and post-anaesthetic phases at Tk III Wijayakusuma Hospital. Method: Employing a descriptive quantitative with a retrospective approach, data were collected by observing 270 anaesthesia records out of a total 303 documents. Completeness was assessed using a checklist based on the hospital’s standardized medical record formats. Result: The results revealed completion rates of 89.6% for pre-anaesthetic assessments, 91.6% for pre-anaesthetic reports, and 67.3% for pre-induction assessments. Intra-anaesthetic reports reached 99.8%, while intra-anaesthetic monitoring stood at 73.8%. Notably, specialized reports for Caesarean sections presented a low completion rate of only 3.9%. Post-anaesthetic assessments and monitoring were recorded at 74.6% and 95.4%. Conclution: These findings indicate that no single documentation indicator achieved full compliance. Strengthening regulations, providing ongoing training, and refining documentation systems are essential to enhance care quality and ensuring patient safety.