ANALYSIS OF COMPLETENESS OF CHILDBIRTH DOCUMENTATION IN THE TPMB IBI WORK AREA MADIUN REGENCY
Keywords:
Analyze, Completeness, Childbirth DocumentationAbstract
Childbirth documentation is an essential component of midwifery services, functioning as legal evidence, a means of communication among health workers, the basis for clinical decision-making. Incomplete documentation is still frequently found in independent midwifery practices. This study aimed to analyze the completeness of childbirth documentation in the TPMB IBI work area Madiun Regency. The method used a quantitative descriptive. The population and sample consisted of 34 independent midwifery practices registered under IBI Madiun Regency, selected using total sampling. Research instruments included questionnaires and checklists. The results showed that most respondents were aged ≥36 years (82.4%), had a D4/S1 education level (94.1%), had established their TPMB for ≥10 years (61.8%), had good knowledge (85.3%), 50% had attended training. Analysis of the completeness level of delivery documentation based on staff capability (58.8%), material support (79.4%), method usage (70.6%), financial availability (76.5%). The completeness level of childbirth documentation was still relatively low, with only 55.9% categorized as complete. TPMB needs continuous practice, standard materials, financial support, implementation procedures, digitization of patient records to improve the quality of childbirth documentation.
Downloads
References
Dewi, S.LG., Sriasih, NGK., Somoyani, NK. (2014)Hubungan Pengetahuan Terhadap Penerapan Pendokumentasian Dengan Metode SOAP. Jurnal Ilmiah Kebidanan (The Jurnal of Midwifery), 2(1). Pp 45-51.
Gusti, R.A. (2021) Sistem Informasi Pengelolaan Rekam Medis dengan Enkripsi Vigenere Cipher. Yogyakarta: Universitas Amikom.
Handiwidjojo, W. (2019). ‘Rekam Medis Elektronik’, Jurnal Eksis, 2, pp. 36–41.
Hatta, G.R. (2008). Modul Audit Pendokumentasian Rekam Medis. Jakarta: Penerbit UI
Hazanah, U. F. (2022). Faktor Kelengkapan Pendokumentasian Asuhan Keperawatan. Skripsi : Universitas dr. Soebandi.
Herdiani, T. & Candratika, M. (2020) ‘Faktor-Faktor yang Berhubungan dengan Kelengkapan Pendokumentasian Asuhan Kebidanan di RSUD Hasanuddin Damrah Manna’, CHMK Midwifery Science Journal, 3, pp. 105–115.
Kementerian Kesehatan Republik Indonesia (2024) Pedoman Asuhan Kebidanan. Jakarta: Kemenkes RI.
Palifiana, D.A. & Wulandari, S. (2021) ‘Penerapan Pendokumentasian Asuhan Kebidanan pada Bidan Praktik Mandiri di Kabupaten Bantul’, Jurnal Keperawatan Intan Husada, 4, pp. 39–49.
Pratama, R.Y., Sohibun & Wagiran (2024) ‘Kelengkapan dan Pendokumentasian Rekam Medis Pasien Ketuban Pecah Dini (KPD)’, Surya Medika: Jurnal Ilmiah Ilmu Keperawatan dan Ilmu Kesehatan Masyarakat, 19(2), pp. 117–127. doi:10.32504/sm.v19i2.812.
Rahmatiqa, C., dkk. (2020) ‘Kelengkapan Berkas Rekam Medis dan Klaim BPJS di RSUD M. Zein Painan’, Jurnal Kesehatan Medika Saintika, 11(1), pp. 11–20. doi:10.30633/jkms.v11i1.514.
Ritonga, Z.A. & Maya, S.F. (2019) ‘Tinjauan Sistem Penyimpanan Berkas Rekam Medis di RSUP H. Adam Malik Tahun 2019’, Jurnal Ilmu Perekam dan Informasi Kesehatan, 4(2), pp. 63–70.
Siagian, S.P. (2016) Manajemen Sumber Daya Manusia. Jakarta: Bumi Aksara.
Surtinah, N.S., dkk. (2019) Buku Ajar Dokumentasi Kebidanan. Magetan: Prodi Kebidanan Magetan.
Talib, M.T. (2022) Implementasi Kebijakan Kesehatan Pelayanan Rekam Medis. Yogyakarta: CV Azka Pustaka.
Uyang, I.T. (2023) ‘Analisis Kelengkapan Rekam Medis Pasien Rawat Jalan di Puskesmas Sungai Siring Samarinda’, Stikes Mutiara Mahakam Journal, 1(1), pp. xx–xx.
Wildan, A. & Hidayat, R. (2019) Dokumentasi Kebidanan. Surabaya: Airlangga University Press.
Yuliani, I. (2020) ‘Documentation of Childbirth Care as Legal Protection for Midwives’ Independent Practices’, Jurnal Kebidanan Indonesia, 6(2), pp. 319–336.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Salsabila Reinsa Novy Nur Fitria, Eltigeka Devi Apriliani

This work is licensed under a Creative Commons Attribution 4.0 International License.



