The Analysis of Predisposing and Reinforcing Factors on the Accuracy of Returning Inpatient Medical Records Documents

Received 16 June 2021 Accepted 26 August 2021 Published 15 September 2021 According to the Procedure Operational Standard of Jember Klinik Hospital, the time for returning medical record documents is 2x24 hours after the patient's discharged from the hospital. Therefore, a medical record document return system is essential to support services, especially medical record document management. Based on the preliminary study, the average rate of returning medical record documents more than 48 hours from January to June 2019 reached 42.3%. The purpose of this study was to analyze the relationship between predisposing and reinforcing factors on the accuracy of returning inpatient medical record documents at the Jember Klinik Hospital. It is a quantitative study with a cross-sectional approach and the spearman rank correlation method. The population of this study was 67 nurses and midwives and 50 respondents as the sample. The results were that there was a significant relationship between knowledge (sig. 0,000), attitude (sig. 0.009), Supervisor’s support (sig. 0.002), and colleagues support (sig. 0.012) on the accuracy of returning medical record documents. However, the variable age (sig. 0.110) of nurses and midwives has no significant relationship with the precision of returning medical record documents. Therefore, this study can be used as a reference in evaluating the accuracy of returning medical record documents. Keyword:

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INTRODUCTION
Medical records are files containing notes and documents about patient identity, examination, treatment, actions, and other services that have been provided to patients (Indonesian Health Ministry, 2008). Medical record documents can be good and complete if they meet the requirements for completeness of content, time accuracy, and meet aspects of legal requirements (Mirfat et al., 2017). Full medical record documentation is a medical record that has been filled in completely by a doctor within 24 hours of completing outpatient services, emergency care, or after an inpatient is decided to go home (Mirfat et al., 2017). Based on the Decree of the Director-General of Medical Services Number YM 00.03.2.2.1996 of 1996, the return of medical record documents is declared late if it exceeds the deadline for returns, a maximum of 2x24 hours the patient is discharged from the hospital.
Predisposing factors are factors that form the basis for someone to behave or can also be said as an innate personal preference factor that can support or inhibit a person to behave in a certain way. The predisposing factors that will be discussed here are knowledge, attitudes, and age.Knowledge of inpatients is an important domain in shaping the actions of officers in returning medical record documents. According to Syamsudin (2016), nurses who have poor knowledge have the opportunity to return medical records late 6,600 times than those with good knowledge. This means that it can be said that the knowledge of inpatients staff, in this case nurses and midwives, is very important. Syamsudin (2016) also said that the better the knowledge of nurses, the more precise the return of medical records.
Attitude is a reaction or response that is still closed from a person to a stimulus or object. Attitude is not an action or activity, but is a predisposition to action or behavior. Syamsudin (2016) states that if the officer's attitude is not good in the accuracy of returning medical record files, this will hinder further activities such as assembling, coding, verifying BPJS claims and filing. Rahayu in Kustianingrum (2018) also mentions that the variables related to the delay in returning medical record files are the knowledge and attitudes of nurses. So that a good attitude for nurses and midwives is an important aspect in the process related to the accuracy of returning medical record documents for nurses and midwives. As well as nurses and midwives age, the age of nurses and midwives is one of the factors related to performance, including in the process of returning medical record documents which is one of the duties of nurses and midwives in inpatient installations (Handayani et al., 2018).
Reinforcing factors include attitudes and behavior of community leaders, religious leaders, attitudes and behavior of health workers. This includes laws, regulations set by the central and local governments related to health, and hospital regulations. Reinforcing factors are also factors that determine whether health actions are supported or not. Positive support from Supervisors will create a conducive work situation. By getting this support, employee performance will be encouraged to be better (Harnida, 2015). This means that supervisor support can affect the performance of nurses and midwives, one of which is in returning medical record documents.Supervisors support is one of the reinforcing factors that can strengthen or weaken a person's behavior (Puspitasari, 2018). Supervisors social support is one of the external factors that can affect the performance of nurses and midwives because a healthy and friendly social environment will also form good interpersonal communication. This will be a support for health workers when working, including the process of returning medical record documents (Iswanto and Agustina, 2016).
From the results of the preliminary study, it is known that the average rate of returning medical record documents to the medical records work unitmore than 48 hours (2x24 hours) from January to June 2019 reached 42.3%. Supposethe Standard Operational Procedure guides it for returning medical record documents at the Jember Klinik Hospital. In that case, the maximum return time is 2x24 hours after the patient goes home or after patient service is completed. Based on the results of an interview in December 2019 with one of the Jember Klinik Hospital officers, stating that medical record documents that often late in returning are inpatient medical record documents, while for outpatient medical record documents there is no delay because nurses immediately return them when the service is finished. The officer also mentioned that the cause of the delay in returning inpatient medical record documents was because filling out medical record sheets could not be done arbitrarily so they still had to wait for the relevant officer to complete the sheet so that the process of returning medical record documents was hampered.
The role of nurses and midwives is vital in returning medical record documents at the Jember Klinik Hospital because according to the Standard Operational Procedure for returning medical record documents that must be replaced. This installation officer borrows, in this case, the nurse and midwife of the installation. The research results conducted by Syamsudin(2016)state a significant relationship between the behavior, attitudes, and knowledge of room nurses onreturning Medical records document to the medical record work unit. The ages of nurses and midwives who work in inpatient wards vary greatly from young to old, so that the resulting work productivity also varies. The research by Handayani et al. (2018)states that the age of health workers affects performance because the effects of poor performance are found in the old age group so that as age increases, work productivity also decreases.
In addition, it was also stated that the role of the head nurse was no less critical in returning this medical record document. The research by Rakhmaningrum(2016)saysthat the support from the supervisor has a relationship to compliance with the return of medical record documents in the medical records section of Dr. Soetomo Hospital. The delay in returning medical record documents at the Jember Klinik Hospital will cause several impacts if it is not resolved immediately, the impacts are including hindering assembling, indexing, and coding activities, slowing down reporting and constraining the BPJS claim process. Syamsudin (2016) states that if the staff is not good in the accuracy of returning medical record files, this will hinder further activities, namely assembling, coding, verifying BPJS claims and filing.
Lawrence Green in Notoatmodjo(2010) states that the factors that influence behavior are divided into 3, including predisposing factors, enabling factors, and reinforcing factors. However, based on the results of the preliminary study and the description of the problem, the researcher found that the tendency of the problem was found in predisposing factors (knowledge, attitudes, and age) and reinforcing factors (support from supervisors and Colleagues), so the researchers intended to analyze the relationship between predisposing and reinforcing factors to the accuracy of returning inpatient medical records at Jember Klinik Hospital.

METHOD
The type of research used in this study is quantitative with the analytical correlation method with the crosssectional approach. The characteristics of the respondent'sinclusion were (i) Jember Klinik Hospital Inpatients Staff; (ii) Willing to be a respondent. The exclusion characteristics of respondents are the subject who is busy and not willing to be a respondent. In addition, there are some special ban from hospitals due to the protocol related to Covid-19.

Sampling procedures
The sampling technique used in this study was a simple random sampling of the inpatient staff of the Jember Klinik HospitalSimple random sampling is sampling in a random way without regard to the strata that exist in the population members (Kustianingrum, 2018).

Sample size, power, and precision
The study was conducted at the Jember Klinik Hospital in June-December 2020.The population in this study was 67 inpatient staff at Jember Klinik Hospital. To calculate the relatively small number of samplesthe slovinformula is used (Notoatmodjo, 2012), and 50 respondents were obtained who would be used as research samples. The research instrument used in this study was a list of questions in the form of a questionnaire to be submitted to 50 inpatient staff at Jember KlinikHospital. Before data collection, respondents explainedby the researchers about this research and filled out the informed consent form. Ethical clearance is submitted before the data collection process is carried out to the KEPK Politeknik Negeri Jember.

Measures and covariates
The type of data used in this study is divided into 2, namely Primary and Secondary. Primary data is obtained from a questionnaire which is aninstrument in the form of a list of questions given to the inpatient room officers of Jember KlinikHospital. Dissemination and collection of data from questionnaires directly by researchers. As for secondary data, namely the monthly report on the return of medical record documents in 2019, the number of inpatient rooms at the Jember Klinik Hospital, and the number of inpatients staff at the Jember Klinik Hospital.
The technique used to collect the research data was a questionnaire given to the inpatient room officers at the Jember Klinik Hospital. Before data collection at the Jember Klinik Hospital, the questionnaire items were tested for validity and reliability at the DKT Baladhika Husada Hospital Jember with 20 respondents.

Data analysis
The data analysis technique in this study is divided into 2, namely Univariate Analysis and Bivariate Analysis. The univariate analysis aims to explain or describe the characteristics of each variable by producing a frequency distribution and percentage of each variable (Notoatmodjo, 2012). The variables defined in this study are independent, namely knowledge, attitudes, age, Supervisors support, and Colleagues support,and the dependent variable is the accuracy of returning inpatient medical record documents. The bivariate analysis aims to determine the relationship between the independent variables (X1-X5) and the dependent variable (Y1) (Notoatmodjo, 2012).
Bivariate analysis was performed using the Spearman Rank statistical test. The Spearman Rank statistical test is a test used to measure the level of closeness of the relationship between two variables with a minimal ordinal scale. Bivariate analysis was carried out through SPSS 24.0 with the criteria for the value of sig. (2-tailed) <0.05 (α) means a significant relationship between variables, the coefficient correlations according to the guidelines, and the direction of the correlation is negative or positive,indicating an increasing or decreasing trend.

The Univariate Analysis of Predisposing Factors and Reinforcing Factors of Inpatients Staff at Jember Klinik Hospital
Based on the research results,most respondents were in a good category, with as many as four variables with good and poor assessment categories and one age variable. The results is that the type of early adulthood were the most common age. For the results of the dependent variable, namely the accuracy of returning medical record documents by nurses and midwives at the Jember Klinik Hospital, most of them were in a good category. It can be seen in Table 1 Table 1 showed that 88% or 44 respondents had good knowledge regarding the accuracy of returning medical record documents. As many as 12% or six respondents had a poor understanding of the accuracy of returning medical record documents. In the attitude variable, 100% or 50 respondents have a good attitude, and as many as 0% or 0 respondents have a bad attitude towards the accuracy of returning medical record documents. For the variable support from Supervisors and colleagues working together as much as 100% or 50 respondents have a good perception, and as many as 0% or 0 respondents have a poor perception. Whereas for the age variable, as many as 64% or 32 respondents had criteria for early adulthood, as many as 16% or eight respondents had criteria for late adulthood, as many as 14% or seven respondents had criteria for late adolescence. As many as 6% orthree respondents had early elderly age criteria. And for the variable accuracy of return, as much as 96% or 48 respondents had good perception. As many as 4% or two respondents had a poor perception of the accuracy of returning medical recorddocuments. The results of hypothesis testing using the spearman rank correlation test between the support of supervisors and the accuracy of returning medical record documents show a significance value ( sig) 0.002 because of the sig. (2-tailed) 0.002 <0.05, it means that there is a significant relationship between the support variable of officers'Supervisors with the accuracy of returning medical record documents, and the correlation coefficient is moderately correlated.

Bivariate Analysis Between Predisposing Factors And Reinforcing Factros to Accuracy in Returning Inpatient
The test results for the colleaguessupport variable to show a significance value (sig) of 0.012 because of the sig. (2tailed) 0.012 <0.05, it means that there is a significant relationship between the support variable of the officer'scolleagueswith the accuracy of returning medical record documents, and the correlation coefficient is moderately correlated.
The correlation coefficient in the table above is positive, namely 0.432 and 0.354 so that the relationship between the two variables is unidirectional relationship type. Thus it can be interpreted that the better the support from Supervisors and colleagues, the better the accuracy in returning medical record documents.

Analysis The Relationship Between Predisposing Factors And Reinforcing Factors On The Accuracy Of Returning Inpatient Medical Record Documents At The Jember Klinik Hospital
Several factors have been examined with the accuracy of returning medical record documents, namely predisposing and reinforcing factors. Predisposing factors consist of knowledge, attitude, and age. Meanwhile, the reinforcing factors consist of supportive Supervisors and support from colleagues.
Based on the study results, the variables of predisposing factors that said there was a relationship with the accuracy of returning medical record documents were knowledge and age variables. It is followingresearch by Nafisatun (2017), which states that there is a significant relationship between knowledge and the timeliness of returning medical record documents at Dr. Moewardi Surakarta Hospital. However, the percentage of respondents' knowledge on the questionnaire about the accuracy of returning medical record documents is known to have the most wrong values, namely the Procedure Operational Standard for returns with the number reaching 50%. Good knowledge will lead to good actions to support quality health services and produce accurate and precise information. Knowledge is information that can change someone or something, where that knowledge becomes the basis for acting, or knowledge that makes an individual have the skills to take the right action (Uyun, 2017). Lack of knowledge can have an impact on work results, meaning that high knowledge can improve the quality of one's work (Octaviantini in Dilla et al., 2020). This is in accordance with this study, it can be seen from the test results which show a strong correlation between knowledge and accuracy of returning medical record documents, besides that the direction of the relationship is also positive, which means that the higher the level of knowledge of the nurse or midwife, the better the level of accuracy return of medical record documents made.
The analysis results for the attitude variable are in line with Syamsudin (2016) research which states that the results of statistical tests obtained a value of P = 0.044, which means that there is a relationship between nurses' attitudes and the return of inpatient medical records. Furthermore, the percentage of inpatient attitudes in returning medical record documents that answer inaccurate respondents reached 22% and 28% in statements related to the person in charge of returns by the Procedure Operational Standard. Syamsudin (2016) states that if officers are not good with the accuracy of returning medical record files, it will hamper further activities, namely assembling, coding, verification of BPJS claims, and filing. Therefore, a good attitude towards the accuracy of returning medical record documents for nurses and midwives is an important aspect. According to (Notoatmodjo, 2010)attitude is also a person's response to a particular stimulus or object, which already involves the opinion and emotion factors concerned (happy-not happy, agree-disagree, good-not good and so on). Some research respondents consider that it is justified not to return medical record documents on time because the officers are still busy in the inpatient room, it can be seen from the results of scoring answers to the questionnaires that have been distributed. The results of this study are in accordance with the case study conducted by Enny Rachmani in Syamsudin (2016) which states that the biggest factor causing delays is the attitude of the respondents who consider services in the inpatient unit more important than returning medical records to the medical record work unit. The attitude of nurses who are not good have a more dominant chance of not being on time in returning inpatient medical records compared to nurses who have a good attitude (Syamsudin, 2016).
The analysis results for the age variable showed no significant relationship with the accuracy of returning medical record documents. It is in line with research by Fitriantoro (2019), which states that age is not a guarantee of the quality of someone's performance. Increasing age without training, learning, and experience will certainly not improve the quality of someone's performance. So that age alone will not play a significant role in someone's performance. It can be proven by the scoring results that are equally well divided between nurses/midwives with good age criteria and nurses/midwives with insufficient age criteria.
Based on the results, the variables of reinforcing factors that said there was a relationship with the accuracy of returning medical record documents supportedSupervisors and colleagues. Itis in line with the research by Rakhmaningrum (2016), which states that the results of the significance test are 0.029 less than 0.05, which means that they support variable from the supervisor has a relationship with the compliance of returning medical record files in the medical records section of Dr. Soetomo Hospital. Positive reinforcement from Supervisors will create a conducive work situation. By getting this support, employee performance will be motivated to be better. Nurses who do not support their leaders make the work cold, unpleasant, dedication and commitment reduced, and performance and worker performance are not optimal (Harnida, 2015).Rosyid and Farhati in Harnida (2015)also say that the absence of superior social support for employees will result in employee burnout which can reduce performance levels. This is in accordance with the results of this study that there is a relationship between supervisor support and the accuracy of returning medical record documents, and besides that the relationship shows a unidirectional which means that the better the support from the nurse /midwife supervisorin this case the head of the inpatient room, the better the accuracy of returning the medical record document.
Research by Iswanto & Agustina (2016)states that there is a very significant positive relationship between colleague's social support and employee performance with a value of r = 0.515 and p = 0.000 (p <0.01). Colleague support is one of the reinforcing factors that can strengthen or weaken the occurrence of a person's behavior (Puspitasari, 2018). Social support can provide various benefits for individuals who receive it. Social support in organizations has an important role to build a healthy and friendly social environment. A healthy and friendly social environment will also form good interpersonal communication. This will be a support for organizational members when working (Iswanto and Agustina, 2016). Social support makes members of the organization enthusiastic to do work even though it feels so heavy. The enthusiasm and support given to members of the organization will be able to change the feeling that was originally bored at work to be cheerful and excited again. This is in accordance with the results of this study, namely that the support of colleagues is positively related to the performance of officers (nurses and midwives) in the effort to return medical record documents, which means that the better the level of social support from colleagues, the better the accuracy of returning medical record documents. In addition, based on the results of filling out questionnaires, nurses or midwives stated that emotional support, feedback, and affirmation of colleagues were important for those with agree and strongly agree answers.

Limitation of The Study
This study only uses a questionnaire as a research instrument. The research was carried out during the pandemic so that nurses/midwives avoid direct contact with outsiders for too long. Besides that, the workload of nurses/midwives also increases, especially on the Covid-19 patient care ward.

CONCLUSIONS
This study concludes that there is a significant relationship between knowledge (sig. 0,000), attitude (sig. 0.009), support from Supervisors (sig. 0.002), and support from colleagues (sig. 0.012) on the accuracy of returning medical record documents. However, the variable age (sig.