Faktor Penyebab Ketidaklengkapan Pengisian Resume Medis Pasien Rawat Inap di Rumah Sakit: Literature Review

Alifah, Safira Nur (2022) Faktor Penyebab Ketidaklengkapan Pengisian Resume Medis Pasien Rawat Inap di Rumah Sakit: Literature Review. Diploma thesis, Politeknik Negeri Jember.

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Abstract

The incompletness of the discharge summary is one of the factors that affect the quality and service of the hospital. Incompletenes in hospital show that the percentage of reaches 50%. This is have an impact on decreasing the quality of hospital service, hospital administration, fulfillment of patient rights and safety. The purpose of this study was to determine the factors causative the incomplete filling of the discharge summary of inpatient at the hospital. This research method is a literature review using articles published in 2011-2021 with 4 database, it is Google Schoolar, Crossreff, Portal Garuda and DOAJ found 20 articles that meet the criteria. The results showed that the incompleted of filling in the discharge summary was due to the implementation of standard operating procedure not being maximized, the doctor’s time being crowded, monitoring and evaluation not being maximized, socialization of standard operating procedures was not maximized, doctor’s attitude and behavior are lacking, doctor’s understanding and knowledge are lacking, understanding and knowledge of medical recorders are lacking, shortage of medical recorders, assembling room is not available, standard operating procedure are not detailed, reward/punishment are lacking, there is no incompleted recapitulation, and limited source of funds. The dominant factor causing the incompleted discharge summary is the implementation of the Standart Operating Procedures has not been maximized. To overcome the incompleted of discharge summary, socialization of standard operating procedures can be carried out, adding human resources, training for doctors and other health workers, monitoring and evaluating regularly and periodically, conducting a reward/punishment, attention to the availability of advice and infrastructure for medical record unit and planning budgeting to support medial record analysis activities.

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