Analisis Faktor Penyebab Ketidaklengkapan Pengisian Berkas Rekam Medis Rawat Inap di Rumah Sakit: Literatur Review

Mahendra, Mochammad Rizqi Putra (2022) Analisis Faktor Penyebab Ketidaklengkapan Pengisian Berkas Rekam Medis Rawat Inap di Rumah Sakit: Literatur Review. Diploma thesis, Politeknik Negeri Jember.

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Abstract

Based on minimum service standards, the completeness rate of inpatient medical record files is 100% and the incompleteness rate is 0%, obtained from Kepmenkes No. 129 of 2008. Some literature still shows the incomplete filling of inpatient medical record files. This is supported by the results of a 40% medical record incompleteness rate, Devhy (2019), which states that the percentage of complete medical records at the Ganesha Hospital in Gianyar City is not yet complete. To achieve the goals of orderly administration and improving service quality, 5m management elements are needed, namely: (man, money, material, machine, method). The purpose of this study was to analyze the factors causing the incomplete filling of inpatient medical record files at the hospital. This study used a literature review method with 21 articles selected according to the inclusion criteria. Using research from articles published from 2011 to 2021. This study uses 5M studies (man, money, material, machine, method). The results obtained occur in medical resume sheets, operating reports, informed consent, doctor's responsibility sheets, service plans, patient status, consent and patient progress notes. The factor of incomplete filling of inpatient medical record files in hospitals is caused by the man factor (human resources) of 33.33%, namely the lack of awareness and compliance. time constraints, and discipline. The money factor (funding) is 19.05% on the variable of limited sources of funds. The material factor (tools) is 23.80% on the variable of inadequate infrastructure. The machine factor (policy) is 28.57% on the variable that there is no socialization about the procedure for administering medical records. The method factor (work procedure) is 19.05% on the variable that there is no monitoring and evaluation of medical record documents and the absence of socialization of SOPs and guidelines for filling out medical records. Keywords: Incompleteness. Medical records. Inpatient

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