scholarly journals Completeness criteria and filling of medical records in dental clinic of Cianjur General Hospital (January - April 2011)

2012 ◽  
Vol 24 (2) ◽  
Author(s):  
Annisa Rosalina ◽  
Netty Suryanti ◽  
Riana Wardani
Keyword(s):  
General Hospital ◽  
Medical Record ◽  
Medical Records ◽  
Random Sampling ◽  
Sampling Technique ◽  
Patient Treatment ◽  
Dental Clinic ◽  
The Republic ◽  
Descriptive Method ◽  
Medical Record Documentation

Introduction: The medical record documentation of patient treatment Provides the which in turn, must be maintained Clearly, concisely, comprehensively and accurately. Medical record and its filling criteria must be based on the regulation of the Minister of Health of The Republic of Indonesia No. 269/Menkes/Per/III / 2008 regarding to the medical record. The research was Aimed to unveil the completeness of both criteria and filling on medical records at the General Hospital’s Dental Polyclinic of Cianjur District. Methods: Survey-based descriptive method was applied within the research. Its Data was acquired through the examination on medical records and interviews. Random sampling was conducted to run the sampling technique. 89 pieces of outpatient’s medical records were embodied as samples. Results: Based on the research results, it is discovered that 6 out of 12 criteria (50%) are not listed within the medical record. Thus, the filling on medical records of 100% is found incomplete. Conclusion: Medical records Dental Clinic Regional General Hospital Cianjur according to standards Permenkes No. 269/2008 not inlude on complete criteria according to standards Permenkes No. 269/2008.

scholarly journals PENGARUH KELENGKAPAN PENGISIAN FORMULIR TRANSFER PASIEN INTERNAL TERHADAP MUTU REKAM MEDIS

2021 ◽  
Vol 10 (2) ◽  
pp. 124-131
Author(s):  
Indar Farwanti Wahyuni
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Random Sampling ◽  
Health Workers ◽  
Sampling Technique ◽  
Simple Random Sampling ◽  
Patient Transfer ◽  
Literature Study ◽  
Number Of Patients

Abstract Internal patient transfer is the process of transferring patients from one room to another in a hospital while still being oriented towards quality and patient safety. The results of the observations showed that the filling of the internal patient transfer form was not optimal so that there were still incomplete forms due to the large number of patients and the weak coordination between health workers. To determine the effect of the completeness of filling out the internal patient transfer form on the quality of medical records. The research method used is quantitative with a descriptive approach. Data collection techniques used are observation, questionnaires and literature study. The sampling technique was simple random sampling technique so as to obtain a sample of 91 internal patient transfer forms. From the results of observations, 22% of the internal patient transfer forms were found that were not completely filled in, especially in the signature and clear name. The two variables have a strong relationship. The effect of the variable completeness of the internal patient transfer form on the medical record quality variable is 90.1% and the remaining 9.9% is influenced by other factors. Based on these studies, it can be concluded that the lack of accuracy and coordination of nurses, doctors and other officers in filling out internal patient transfer forms so that this affects the quality of medical records in the aspect of accuracy. Keyword : Completeness, Internal Patient Transfer Form, Medical Record Quality   Abstrak Transfer pasien internal merupakan proses pemindahan pasien dari satu ruangan ke ruangan yang lain di dalam satu rumah sakit dengan tetap berorientasi pada mutu dan keselamatan pasien. Hasil observasi menunjukkan bahwa belum optimalnya pengisian formulir transfer pasien internal sehingga masih terdapat formulir yang tidak lengkap disebabkan oleh faktor dari banyaknya pasien dan lemahnya koordinasi antara tenaga kesehatan. Untuk mengetahui pengaruh kelengkapan pengisian formulir transfer pasien internal terhadap mutu rekam medis. Metode penelitian yang digunakan yaitu kuantitatif dengan pendekatan deskriptif. Teknik pengumpulan data yang digunakan adalah observasi, kuesioner dan studi pustaka. Teknik pengambilan sampel adalah teknik simple random sampling sehingga memperoleh sampel sebanyak  91 formulir transfer pasien internal. Dari hasil observasi ditemukannya formulir transfer pasien internal yang belum terisi lengkap sebanyak 22% terutama pada tandatangan dan nama jelas. Kedua variabel memiliki hubungan yang kuat. Pengaruh variabel kelengkapan formulir transfer pasien internal terhadap variabel mutu rekam  medis sebesar 90,1% dan sisanya 9,9% dipengaruhi oleh faktor lain. Berdasarkan penelitian tersebut dapat disimpulkan bahwa kurangnya ketelitian dan koordinasi perawat, dokter dan petugas lain dalam pengisian formulir transfer pasien internal sehingga hal ini mempengaruhi mutu rekam medis pada aspek keakuratan. Kata kunci: Kelengkapan, Formulir Transfer Pasien Internal, Mutu Rekam Medis

scholarly journals HUBUNGAN SEROTINUS DENGAN KEJADIAN ASFIKSIA BAYI BARU LAHIR DI RUMAH SAKIT UMUM DAERAH KOTA KENDARI TAHUN 2015

2018 ◽  
Vol 10 (1) ◽  
Author(s):  
Elyasari . ◽  
Listi .
Keyword(s):  
Data Analysis ◽  
General Hospital ◽  
Medical Record ◽  
Research Methods ◽  
Random Sampling ◽  
Sampling Technique ◽  
Case Control ◽  
Systematic Sampling ◽  
City Hospital ◽  
The Relationship

Newborn asphyxia is a condition where the baby is born can not immediately breathe spontaneously and regularly after birth (Wiknjosastro, 2007). AKB in Kendari City in 2014 as many as 26 people out of 6,228 newborns with the incidence of asphyxia in newborns in Kendari City General Hospital in 2015 as many as 78 people out of 950 newborns and the number of infants experiencing serotinus as many as 40 babies (Medical Record of Kendari City Hospital, 2015). Objective: To determine the relationship between serotinus and the incidence of asphyxia in newborns at the Kendari Regional General Hospital in 2015. Research methods: The type of research used was analytic with the design of Case Control. The sampling technique was purposive sampling, in which all asphyxial infants were taken as a case. The systematic sampling technique was random sampling, where all non-asphyxial infants were numbered, and from 872 non-asphyxial infants divided by the number of controls taken 872: 78 = 11.2, so that the sample for control is a multiple of 11. The results of the study: based on data analysis obtained results, namely from 78 infants with asphyxia there were 10 people (12.8%) babies born with serotinus. The value of X2counts 5,778> X2 table 3,841 so that H0 is rejected and Ha is accepted with OR = 5.588 (p= 0.032). Conclusion: There is a relationship between serotinus and the incidence of asphyxia in newborns in Kendari Regional General Hospital in 2015

scholarly journals ANALISIS LUAS RUANGAN BERDASARKAN KEBUTUHAN RAK DI RUANG PENYIMPANAN BERKAS REKAM MEDIS RAWAT JALAN DI RUMAH SAKIT UMUM MADANI MEDAN TAHUN 2019

2020 ◽  
Vol 5 (1) ◽  
pp. 20-29
Author(s):  
Puput Melati Hutauruk ◽  
Fince Rahmat Zega
Keyword(s):  
General Hospital ◽  
Medical Record ◽  
Medical Records ◽  
Patient Medical Record ◽  
File Storage ◽  
Storage Room ◽  
Quantitative Descriptive ◽  
Storage Racks ◽  
Descriptive Method

ABSTRAK Rekam medis disimpan dalam rak penyimpanan agar terjaga kerahasiaanya, terhindar dari kerusakan dan mempermudah petugas dalam pengambilan dan pengembalian rekam medis. Agar pelayanan menjadi efektif dan efesien, selain memerlukan rak penyimpanan yang cukup, juga perlu ruangan penyimpanan yang bisa memuat rak penyimpanan tersebut agar dapat menyimpan berkas rekam medis pasien dalam jangka waktu tertentu guna pemeriksaan diwaktu yang akan datang dan memudahkan pengambilan kembali oleh petugas. Maka dari itu peneliti bertujuan untuk menegetahui luas ruangan berdasarkan kebutuhan rak saat ini di Rumah Sakit Umum Madani Medan tahun 2019. Penelitian ini menggunakan  metode deskriptif kuantitatif yaitu dengan memaparkan hasil penelitian apa adanya dan membandingkan dengan teori kemudian diambil kesimpulan. Subjek dalam penelitian ini adalah ruang penyimpanan berkas rekam medis rawat jalan, dan objek dalam penelitian ini adalah berkas rekam medis dan rak penyimpanan rawat jalan. Hasil penelitian ini menunjukkan bahwa jumlah rak penyimpanan berkas rekam medis rawat jalan di RSU Madani medan adalah 8 rak dengan luas ruangan 18,99 m2. Jika saat ini rumah sakit memiliki 8 rak, maka rumah sakit perlu menyediakan 10 rak lagi sehingga luas ruangan menjadi 48,82 m2 agar luas ruangan dapat tercukupi dan dapat memuat rak sesuai kebutuhan rumah sakit  sehingga tidak menyulitkan petugas penyimpanan dalam pengambilan maupun pengembalian rekam medis pasien.   Kata Kunci    :  Rekam Medis, Rak Penyimpanan, Luas Ruangan   ABSTRACT Medical records are stored in a storage rack to maintain confidentiality, avoid damage and make it easier for officers to retrieve and return medical records. In order for the service to be effective and efficient, in addition to requiring adequate storage shelves, storage rooms that can also contain storage shelves are needed so that they can store patient medical record files for a certain period of time for future examinations and facilitate retrieval by officers. Therefore the researcher aims to determine the area of ​​the room based on the needs of the current shelves at the Medan Madani General Hospital in 2019. This research uses a quantitative descriptive method by describing the results of the research as it is and comparing with the theory then conclusions are drawn. The subjects in this study were the outpatient medical record file storage room, and the object in this study was the medical record file and outpatient storage rack. The results of this study indicate that the number of outpatient medical record file storage racks in Medan Madani General Hospital is 8 shelves with an area of ​​18.99 m2. If the hospital currently has 8 shelves, the hospital needs to provide 10 more shelves so the room area becomes 48.82 m2 so that the room area can be fulfilled and can load the shelves according to the hospital's needs so that it does not make it difficult for the storage staff to retrieve or return the patient's medical record .

scholarly journals Prediction of active filing shelf in medical record unit - General hospital Dr. H. Soewondo Kendal 2020 – 2024

2020 ◽  
Vol 13 (3) ◽  
pp. 001-007
Author(s):  
Prasetya Jaka ◽  
Isworo Slamet
Keyword(s):  
Linear Regression ◽  
General Hospital ◽  
Medical Record ◽  
Medical Records ◽  
Sampling Technique ◽  
Systematic Sampling ◽  
Regression Equations ◽  
Medical Support ◽  
Observation Results

General hospital Dr. H. Soewondo Kendal is a local government hospital. Improving medical support services, especially the quality of medical record archiving services, is essential to maintain the quality of hospitals in the context of good hospital standards. This study aims to predict the need for archive shelves between 2015-2019. The type of research used is descriptive with accidental sampling technique. Patient medical records were collected using a systematic sampling technique. The observation results showed that the average thickness of medical record documents was 0.85 cm based on measurements on 30 samples of medical record documents. The hospital has 48 shelves with 5 sub-shelves on each shelf. The length of the available archives is 525 cm and by 2024 a total of 37 shelfs will be needed. Modeling results based on linear regression equations have decreased medical record documents since 2015-2019 y = - 782.9x +30636. However, the linear regression validation for the cumulative medical record documents for 2015-2019 shows an increase based on the regression equation y = 28439 x + 1112.2, therefore it is necessary to immediately save the medical record document in an active state. The conclusion delivered by Dr. H. Soewondo Kendal does not need an additional archive shelf, but it does require inactive document storage.

scholarly journals Gambaran Penggunaan Bahan Restorasi Resin Komposit di Balai Pengobatan Rumah Sakit Gigi dan Mulut Universitas Sam Ratulangi Tahun 2011 - 2012

e-GIGI ◽  
2013 ◽  
Vol 1 (2) ◽  
Author(s):  
Pingkan Sajow
Keyword(s):  
Dental Caries ◽  
Medical Records ◽  
Random Sampling ◽  
Composite Resin ◽  
Public Awareness ◽  
Sampling Technique ◽  
Research Data ◽  
Filling Material ◽  
Dental Clinic ◽  
Composite Resin Restorations

Karies gigi merupakan salah satu penyakit yang sering dialami oleh setiap individu. Perubahan tingkat ekonomi dan pola hidup menjadi beberapa penyebabnya. Kurangnya kesadaran masyarakat akan kesehatan gigi dan mulut juga menjadi salah satu penyebab karies pada gigi. Gigi yang karies sebaiknya segera dilakukan perawatan menggunakan salah satu bahan restorasi yang sering digunakan saat ini yaitu resin komposit.Penelitian ini bertujuan untuk mengetahui gambaran penggunaan resin komposit sebagai bahan restorasi gigi di Balai Pengobatan Rumah Sakit Gigi dan Mulut (BP-RSGM) Universitas Sam Ratulangi pada tahun 2011-2012. Jenis penelitian ini merupakan penelitian deskriptif dengan pengambilan data berdasarkan rumus Slovin yang ditentukan dengan menggunakan teknik random sampling dari rekam medis pasien yang ditumpat dengan resin komposit di BP-RSGM pada tahun 2011-2012. Jumlah data penelitian yang diambil yaitu 85 pasien dengan 108 gigi yang direstorasi dan dikategorikan berdasarkan jenis kelamin, pekerjaan pasien, tahun restorasi, umur pasien, regio gigi, jumlah gigi dan diagnosa penyakit.Hasil penelitian menunjukkan pada tahun 2012 telah terjadi peningkatan dalam penggunaan resin komposit dibandingkan pada tahun 2011. Perawatan dengan resin komposit lebih sering dilakukan oleh pasien yang berjenis kelamin perempuan dan sebagian besar telah berusia dewasa. Regio anterior merupakan regio gigi yang paling banyak mendapatkan restorasi dengan resin komposit dan penyakit gigi yang paling sering didiagnosa ialah pulpitis reversibel. Pada setiap pasien terdapat minimal 1 gigi yang ditumpat dengan resin komposit.Kata kunci: Resin komposit, karies gigiABSTRACTDental caries is one of the most common sickness suffered by every people. Alterations in the economy and lifestyle are some of the causes. Lack of public awareness towards oral health is also one of the causes of dental caries. Dental caries should be taken care and one materials of the filling that are often used today is composite resin.The purpose of this research is to know about the use of composite resin as restoration material in the Dental Clinic of Sam Ratulangi University in 2011-2012. This research is a descriptive retrospective research using the Slovin formulae and the random sampling technique approach by taking the medical records of patients at the Dental Clinic in 2011-2012 whom were given composite resin as the filling material. The amount of research data retrieved were of 85 patients with 108 teeth filled by composite resin and are categorized based of sex, patient activity,on the year of filling, age, region of filling, the number of teeth filled in each patient and diagnoses.The results show that in the year of 2012 the use of composite resin restorations has increased in comparison to the year of 2011. Treatment with a composite resin is more often performed on female patients and most of them being adults. The anterior region of the teeth is the region most filled by composite resin and is most commonly diagnosed with pulpitis reversible. In each patient there is at least one tooth that is filled by composite resin.Keywords: Composite resin, dental caries

Analisis Unsur Manajemen dalam Pengolahan Rekam Medis di Rumah Sakit TNI AU Lanud Roesmin Nurjadin

2018 ◽  
Vol 1 (1) ◽  
pp. 20-25
Author(s):  
Henny Maria Ulfa
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Processing Method ◽  
Qualitative Approach ◽  
Check List ◽  
Training Material ◽  
Patient Medical Record ◽  
Qualitative Descriptive ◽  
Material Element ◽  
Descriptive Method

Hospitals must conduct a medical record activities according to Permenkes NO.269 / MENKES / PER / III / 2008 about Medical Record, to achieve the purpose of medical record processing required 5 management elements are: man, money, material, machine, and method. The medical record processing that has been implemented at the Hospital TNI AU LANUD Roesmin Nurjadin that is coding, coding only done for BPJS patients whose conducted by the officer with education background of D3 nursing, it be impacted to the storage part is wrong save and cannot found patient medical record file because are not returned. The purpose of this research is to know the element of management in the processing of medical records at the Hospital TNI AU LANUD Roesmin Nurjadin. This research is done by Qualitative descriptive method, Qualitative approach, instrument of data collection of interview guidance, observation guidance, check list register, and stationery, number of informant 6 people with inductive way data analysis. The result of this research found that Mans elements only amounts to 2 people so that officers work concurrently and have never attended training, material element and machines elements of medical record processing not yet use SIMRS and tracer, while processing method elements follow existing habits and follow the policy of hospital that is POP organization. Keywords: Management elements, medical record processing

KONTRIBUSI PENGUASAAN KALIMAT EFEKTIF TERHADAP KETERAMPILAN MENULIS TEKS EKSPOSISI SISWA KELAS X SMK NEGERI 2 PADANG

2019 ◽  
Vol 8 (3) ◽  
pp. 78
Author(s):  
Diana Citra ◽  
Afnita Afnita
Keyword(s):  
Random Sampling ◽  
Writing Skills ◽  
Sampling Technique ◽  
First Year ◽  
Performance Tests ◽  
First Year Students ◽  
Correlational Design ◽  
Writing Skill ◽  
And Performance ◽  
Descriptive Method

ABSTRACT The purpose of this study was categorized into three. First, to describe the effective sentence mastery of the first year students at SMK Negeri 2 Padang. Second, to describe the writing skills of a exposition of the first year students at SMK Negeri 2 Padang. Third, to describe the contribution of the effective sentence mastery into the writing skills of a exposition text made by the first year students at SMK Negeri 2 Padang. The design of this research was quantitative with a descriptive method. Then, this study also was a correlational design. The population of this study was the first year students at SMK Negeri 2 Padang for about 498 students. The sample of this study was taken by using a proportional random sampling technique (15%), which was 70 students. The data of this study were the results of effective sentence mastery and the results of the writing skill of a exposition text. The instrument of this study was an objective test to measure effective sentence mastery and performance tests to measure expositon text. There were several results of this study. First, the effective sentence mastery of the first year students at SMK Negeri 2 Padang was in Good qualifications (B). Second, the writing skills of a exposition of the first year students at SMK Negeri 2 Padang was in a Good qualification (B). Third, describe the effective sentence mastery contributed 82,00% to the exposition text writing skills of the first year students of SMK Negeri 2 Padang. Kata Kunci: kontribusi, penguasaan kalimat efektif,  keterampilan menulis teks eksposisi 

Peranan Promosi Jabatan Dalam Meningkatkan Semangat Kerja Karyawan Pada Kantor Asuransi Jasa Indonesia (Persero) Cabang Garut Ritel

KarismaPro ◽  
2021 ◽  
Vol 1 (2) ◽  
Author(s):  
Eny Nuryani
Keyword(s):  
Random Sampling ◽  
Rank Correlation ◽  
Sampling Technique ◽  
Coefficient Of Determination ◽  
Employee Morale ◽  
Spearman Rank Correlation ◽  
Verification Method ◽  
Job Promotion ◽  
Descriptive Method

One of the efforts taken by the company to improve morale is to meet the promotion appropriately, because when promotions are met then the employee will contribute optimum morale. The purpose of this study is to investigate the implementation of a promotion, the condition of employee morale and job promotion role in improving employee morale at PT. Asuransi Jasa Indonesia (Persero) Branch Garut Retail.The analytical method used in this research is descriptive and verification method. Descriptive method used to determine the implementation of promotion and conditions of employee morale at PT. Asuransi Jasa Indonesia (Persero) branch of Garut Retail, the verification method used to determine the role of promotion in improving employee morale at the office of PT. Asuransi Jasa Indonesia (Persero) branch Retail Garut.The method used is survey explanation. The process of sampling carried out by random sampling technique. The sample size is 65 people. The data collection was conducted using questionnaires, interviews, and literature.These results indicate that the promotion included in the category of good, as well as morale is also high. It is seen that the coefficient of determination variable X amounted to 16.56%, and the remaining 83.44% is the influence of other factors. Spearman Rank Correlation promotion variables play a role in improving employee morale with a yield of 0,407 and have a relationship and the variables that are significant

scholarly journals PENGARUH DIKLAT FUNGSIONAL PERENCANA DAN MOTIVASI KERJA TERHADAP KUALITAS PERENCANA (STUDI DI BAPPENAS TAHUN 2016)

2017 ◽  
Vol 3 (2) ◽  
pp. 33-57
Author(s):  
Ivan Budi Susetyo ◽  
Frans Dione ◽  
Eko Hari
Keyword(s):  
Random Sampling ◽  
Work Motivation ◽  
Sampling Technique ◽  
Positive Influence ◽  
Faculty Training ◽  
Stratified Random Sampling ◽  
Functional Training ◽  
Need For Power ◽  
Descriptive Method

Abstract: The formulation of this study is review the influence of functional training planners to the quality planners, the influence of work motivation to the quality of planner, and the influence of functional training planners and motivation to work together to the quality of Bappenas planners. The method used in this research is descriptive method with quantitative approach. The sampling technique is using proportionate stratified random sampling with a number of sample sizes of 137 people. Furthermore, the data obtained, processed and analyzed with SPSS 19.0 for windows Program by performing statistical test, those are the t test and F test. The results of this study indicate that there is a positive influence between functional training planners to quality planners, work motivation to quality planners, and the influence of the two together to the quality planner. The dimension of functional training planners that have an influence to the quality of planners is the management and faculty training. In addition, the study is also found that the dimension of work motivation which has an influence to the quality of planners is the need for achievement and the need for power. Keywords: Training, Work Motivation, Quality Planner Abstrak: Perumusan penelitian ini mengkaji besarnya pengaruh diklat fungsional perencana terhadap kualitas perencana, pengaruh motivasi kerja terhadap kualitas perencana, dan pengaruh diklat fungsional perencana dan motivasi kerja secara bersama-sama terhadap kualitas perencana Bappenas. Metode penelitian yang digunakan dalam penelitian ini adalah metode penelitian deskriptif dengan pendekatan kuantitatif. Populasi dalam penelitian ini adalah seluruh perencana di Bappenas tahun 2016. Teknik pengambilan sampel menggunakan proportionate stratified random sampling dengan jumlah ukuran sampel 137 orang. Selanjutnya, data yang diperoleh, diolah dan dianalisa  dengan bantuan program SPSS 19.0 for windows dengan melakukan uji statistik yaitu uji t dan uji F. Hasil penelitian ini menunjukkan bahwa terdapat pengaruh positif antara diklat fungsional perencana terhadap kualitas perencana, motivasi kerja terhadap kualitas perencana, dan pengaruh keduanya secara bersama-sama terhadap kualitas perencana. Dimensi diklat fungsional perencana yang memiliki pengaruh terhadap kualitas perencana adalah pengelolaan dan tenaga pengajar diklat. Selain itu, penelitian juga menemukan bahwa dimensi motivasi kerja yang memiliki pengaruh terhadap kualitas perencana adalah kebutuhan akan prestasi dan kebutuhan akan kekuasaan. Kata Kunci: Diklat, Motivasi Kerja, Kualitas Perencana

scholarly journals QUANTITATIVE EVALUATION OF MEDICAL RECORD DOCUMENTATION IN IMAM REZA HOSPITAL, MASHHAD, IRAN

2017 ◽  
Vol 1 (4) ◽  
pp. 98-99
Author(s):  
Zahra Mazloum khorasani ◽  
Mahmood Tara ◽  
Kobra Etminani ◽  
Zohre Moosavi ◽  
Zahra Ebnehoseini
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Qualitative Evaluation ◽  
Cross Sectional Study ◽  
Diabetic Patients ◽  
Cross Sectional ◽  
Accurate Treatment ◽  
Diabetes Center ◽  
Data Elements ◽  
Medical Record Documentation

Introduction: Diabetes is the most common endocrine disease. Given the importance of medical record documentation for diabetic patients and its significant impact on accurate treatment process, as well as early diagnosis and treatment of acute and chronic complications, this study aimed to qualitatively evaluate medical record documentation of diabetic patients. Methods: This descriptive and cross-sectional study was conducted on all medical records of diabetic patients (1200 cases) in the comprehensive Diabetes Center of Imam Reza Hospital. A checklist was prepared according to the main sectors and their sub-data elements to conduct a qualitative evaluation on documentation of medical records of diabetic patients.  Descriptive statistics were used to report the results. Results: In this study, 1200 (710 women and 490 men) cases were evaluated. Mean documentation of main sectors of diabetic patients’ records were as follows: 49% demographic characteristics, 14% patient referral, 4% diagnosis, 50% lab tests, 25% diabetes medications,13% nephropathy screening test, 10% diabetic neuropathy, 41% specialty and subspecialty consultations and internal medicine physicians visits did not complete for all the patients. Conclusion: According to the results of this study, qualitative evaluation of medical record documentation of diabetic patients Showed poor documentation in this regard. It is suggested that results of this study be accessible to physicians of healthcare centers to take a positive step toward improved documentation of medical records. In addition, it seems necessary to modify diabetic medical records.

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