Analisis Faktor Penyebab Ketidaklengkapan Pengisian Berkas Rekam Medis Pasien Rawat Inap Di Rumah Sakit: Literature Review

Verawati, Maria (2021) Analisis Faktor Penyebab Ketidaklengkapan Pengisian Berkas Rekam Medis Pasien Rawat Inap Di Rumah Sakit: Literature Review. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

The completeness of medical records has a role in improving health services in hospital with standard 100% of completeness. If the inpatient medical record is incomplete, it will have an impact the continuity of service and patient safety. The purpose of this study was to analyze causing factor incomplete filling of medical record files of inpatients at the hospital using 5M management elements, Man, Money, Method, Material, and Machine. The method used in this study is literature review. Selection of literature based on inclusion and exclusion criteria. The databases used are Google Scholar, Crossref, e-Library Politeknik Negeri Jember, and Portal Garuda. The amount of literature found was 16 articles, consisting of 14 journals and 2 essays. The result obtained in this study are the man element due to indiscipline, high workload, inappropriate educational background, knowledge of the benefits, usefulness and impact of incompleteness, training, and age, tenure of officers, element of money due to limited budgets, the method element is due to the implementation not being in accordance with the SOP (Standard Operational Procedure) and the lack of socialization of the SOP, there’s no reward and punishment system, less effective monitoring and evaluation and monitoring and evaluation have not been carried out, material elements due to less systematic form arrangement, and machine elements due to inadequate facilities and infrastructure. To break the back the problem, providing training, preparing exclusively budgets, conduct socialization of SOP, improve form design structure, monitoring and evaluating SOP’s, impose reward and punishment for officers, and complete the facilities and infrastructure

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