Analisis Perbedaan Kelengkapan Rekam Medis Rawat Inap Berdasarkan Metode Open Review dan Close Review di Ruang Rawat Inap Kasuari Rsup dr. Kariadi Semarang Tahun 2021

Latif, Muhamad Nasrul (2022) Analisis Perbedaan Kelengkapan Rekam Medis Rawat Inap Berdasarkan Metode Open Review dan Close Review di Ruang Rawat Inap Kasuari Rsup dr. Kariadi Semarang Tahun 2021. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Filling in the medical records of inpatients at the dr. Kariadi still found many incomplete. The preliminary survey found that the monthly average from January to March 2021, the percentage of incomplete medical records for patients in the 5th floor cassowary room reached 100% and the 4th floor cassowary room reached 99.64% incomplete medical records. The purpose of this study was to analyze differences in the completeness of inpatient medical records based on the open review and close review methods in the cassowary room. The data collection technique was carried out by observation using a checklist sheet. The results obtained in the open review of the lowest completeness score obtained 30.49% integration sheet and 45.12% complete medical assessment sheet. Calculations with a close review have the lowest completeness score obtained by an integration sheet with a value of 30.49% and an assessment sheet of 47.56%. The calculation of the Chi Square test and the alternative test of eight subvariables in this study showed that there were two sub-variables that had a value less than = 0.05, namely the approval sheet for the completeness of content aspect with a value of value of 0.000 and the education sheet for recording aspects of time and date with p value of 0.013. The other six variables show that p value is greater than = 0.05. The conclusion of this study is that there is a difference in the assessment of completeness with the open review method with a close review on the variables of completeness of the contents of the action agreement and recording the time and date of the education sheet while the other variables have no difference. Suggestions for the person in charge of the medical record quality should carry out a routine evaluation of the results of the assessment of the completeness of the medical record with the open review and close review methods that have been carried out in order to improve the quality of medical records.

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