HUBUNGAN INTERPROFESSIONAL COLLABORATION DENGAN KUALITAS DOKUMENTASI KLINIS PASIEN DI RAWAT INAP RSUD BENGKALIS

Abstract

Health services in hospitals require effective interprofessional collaboration supported by accurate clinical documentation. Interprofessional Collaboration (IPC) is an important approach for improving the quality of healthcare services, including the quality of patients’ clinical documentation recorded in the Integrated Patient Progress Notes (CPPT). This study aimed to analyze the relationship between IPC and the quality of patients’ clinical documentation in the inpatient wards of RSUD Bengkalis. A quantitative analytic design with a cross-sectional approach was used. The sample comprised 67 multiprofessional healthcare workers selected through purposive sampling. Data were collected using the Assessment of Interprofessional Team Collaboration Scale II (AITCS-II) questionnaire and an observation checklist for documentation quality, and were analyzed using univariate, bivariate, and multiple logistic regression. Most respondents had a moderate level of IPC (62.7%), and most documentation was categorized as moderately complete (52.2%). Bivariate analysis showed a significant association between IPC and documentation quality (p < 0.001). After adjusting for professional field as a covariate, IPC remained the only significant predictor of documentation quality in the final multiple logistic regression model (OR = 23.467; 95% CI: 5.788–95.138; p < 0.001; Nagelkerke R² = 0.460), although other potential confounders such as age, education, employment status, and length of service were not included in the model. In conclusion, IPC is significantly associated with the quality of patients’ clinical documentation at RSUD Bengkalis; strengthening interprofessional collaboration is recommended as a priority for quality improvement, and future multi-center studies with more comprehensive confounder control are recommended to strengthen this estimate.