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The material identifies participating roles including general practitioners, nurses, and medical record officers, along with service-length profiles. Problem scoring highlights key obstacles such as insufficient attention to detail, limited training, and suboptimal SOP implementation, while ranking indicates priority issues. An improvement plan then specifies actions for detail verification, staff guidance and training, network reliability measures, and routine SOP dissemination.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":51,"@type":70,"position":76},"https://docshare.wps.com/template/general/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/medical-record-documentation-assessment-and-improvement-plan/191490/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/medical-record-documentation-assessment-and-improvement-plan/191490.png","ImageObject",442,249,{"name":88,"@type":89},"Oliver Hayes","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-27","2026-09-03",true,{"@type":98,"interactionType":99,"userInteractionCount":47},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"How is completeness of incoming medical record files measured in the document?","Question",{"text":108,"@type":109},"Completeness is tracked by counting the number of incoming files and the number of incomplete files per date, then calculating the percentage of incompleteness.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Which documentation elements are most strongly linked to authentication and high-frequency records?",{"text":113,"@type":109},"Authentication has the highest frequency and percentage among the listed fields, while many patient-identifying and administrative fields show zero frequency.",{"name":115,"@type":106,"acceptedAnswer":116},"What improvement actions are proposed to address low documentation quality?",{"text":117,"@type":109},"The plan includes routine rechecking before submission, guidance and supervision with training for staff, reducing electrical equipment load while improving network reliability, and conducting regular SOP guidance and dissemination with SOP documents provided in each service unit.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},191490,1788408904,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":50,"category_name":51,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":47,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":47,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":125,"read_time":73},687207020761,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","| Date | Number of incoming files | Number of\u003Cbr>incomplete files | Percentage of\u003Cbr>incompleteness |\n| --- | --- | --- | --- |\n| June 9, 2022 | 36 | 2 | 5.6 |\n| June 10, 2022 | 37 | 5 | 13.5 |\n| June 11, 2022 | 37 | 2 | 5.4 |\n| June 13, 2022 | 33 | 3 | 9.1 |\n| June 14, 2022 | 53 | 3 | 5.7 |\n| June 15, 2022 | 30 | 4 | 13.3 |\n| June 16, 2022 | 41 | 3 | 7.3 |\n\n\n| Description | Frequency | Percentage |\n| --- | --- | --- |\n| Medical record number | 0 | 0 |\n| Patient name | 0 | 0 |\n| Address | 0 | 0 |\n| Occupation | 0 | 0 |\n| Index number | 0 | 0 |\n| Bpjs/spm number | 0 | 0 |\n| Date ofbirth | 0 | 0 |\n| Date and time ofexamination | 0 | 0 |\n| Nursing documentation | 3 | 13.6 |\n| Authentication | 19 | 86.4 |\n\n\n| No. | Name | Position | Length ofservice |\n| --- | --- | --- | --- |\n| 1 | Respondent 1 | General practitioner | 5 months |\n| 2 | Respondent 2 | General practitioner | 5 years |\n| 3 | Respondent 3 | Nurse | 17 years |\n| 4 | Respondent 4 | Nurse | 2 years |\n| 5 | Respondent 5 | Medical record officer | 3 years |\n| 6 | Respondent 6 | Medical record officer | 3 years |\n\n\n| No | Category | Non-civil\u003Cbr>servants | Civil\u003Cbr>servants | Total |\n| --- | --- | --- | --- | --- |\n| 1 | General practitioners | 1 | 1 | 2 |\n| 2 | Nurses | 25 | 12 | 37 |\n| 3 | Medical record officers | 2 | - | 2 |\n\n\n| No. | Profession | Job description |\n| --- | --- | --- |\n| 1 | General practitioner | a. Provide outpatient medical services\u003Cbr>b. Analyze patient examination data to prepare medical records\u003Cbr>c. Complete medical records accurately, including ICD-10 diagnosis coding |\n| 2 | Nurse | Document medical records accurately and completely, including diagnosis coding according to ICD-10 |\n| 3 | Medical record officer | Perform medical record services and registration tasks and coordinate with related programs according to procedures |\n\n\n| No. | Problem | Score | Ranking |\n| --- | --- | --- | --- |\n| 1 | Limited work experience among some medical staf | 45 | VII |\n| 2 | Lack of training in medical record documentation | 48 | V |\n| 3 | Absence of control cards for incomplete records | 46 | VI |\n| 4 | Computer network instability | 57 | II |\n| 5 | Insufficient staff during peak patient visits | 51 | IV |\n| 6 | Lack of budget for training | 43 | VIII |\n| 7 | Additional workload beyond primary job descriptions | 46 | VI |\n| 8 | Suboptimal implementation ofSOPs | 52 | III |\n| 9 | Lack of attention to detail in documentation | 59 | I |\n| 10 | Absence of punishment for incomplete documentation | 46 | VI |\n\n\n| No. | Problem | Improvement Plan |\n| --- | --- | --- |\n| 1 | Lack of attention to detail | a. Conduct routine rechecking of records before submission\u003Cbr>b. Provide guidance, supervision, and training |\n| 2 | Computer network instability | a. Reduce use of high-power electrical equipment\u003Cbr>b. Allocate budget for electrical system improvements |\n| 3 | Suboptimal SOP\u003Cbr>implementation | a. Conduct regular guidance on roles and SOPs\u003Cbr>b. Disseminate SOPs routinely\u003Cbr>c. ProvideSOP documents in each service unit |","cbCaitDksCmLey8D","https://ap.wps.com/l/cbCaitDksCmLey8D","pdf",53016,"English","# Assessment overview\n## Incoming file completeness by date\n## Documentation fields and authentication frequency\n## Respondent profiles and staffing categories\n# Problem analysis and ranking\n## Identified problems and scores\n# Improvement plan\n## Targeted actions for each problem","[{\"question\":\"How is completeness of incoming medical record files measured in the document?\",\"answer\":\"Completeness is tracked by counting the number of incoming files and the number of incomplete files per date, then calculating the percentage of incompleteness.\"},{\"question\":\"Which documentation elements are most strongly linked to authentication and high-frequency records?\",\"answer\":\"Authentication has the highest frequency and percentage among the listed fields, while many patient-identifying and administrative fields show zero frequency.\"},{\"question\":\"What improvement actions are proposed to address low documentation quality?\",\"answer\":\"The plan includes routine rechecking before submission, guidance and supervision with training for staff, reducing electrical equipment load while improving network reliability, and conducting regular SOP guidance and dissemination with SOP documents provided in each service unit.\"}]","Medical Record Documentation Assessment and Improvement Plan | PDF"]