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October 15, 2025

Medical Record Audit of Patients with Diabetes Mellitus, Gastroenteritis, and Pneumonia

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Authors

ESEka Nur SafitriMTM TajuddinUNUmi Khoirun Nisak

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Overview

Analysis of medical record completeness for diabetes mellitus, gastroenteritis, and pneumonia patients reveals low standards, indicating urgent need for improvement.

Key Points

  • The audit revealed a low completeness rate of 23.7% for social data and 30.3% for record evidence among patients.
  • Relative record validity was recorded at 67.1%, while recording procedure completeness stood at 56.6% in the analyzed records.
  • This analysis utilized a quantitative approach on 76 inpatient records from October 2021 to October 2022 across three conditions.
  • The findings highlight potential risks in documentation accuracy, emphasizing the need for continuous audits for quality assurance.

Cite This Study

Safitri et al. (2025) studied this question.

synapsesocial.com/papers/68efd921056559ef428776a6https://doi.org/10.21070/ijhsm.v2i2.220
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