ANALISIS PENGELOLAAN DOKUMEN REKAM MEDIS RAWAT INAP BAGIAN ASSEMBLING DI RUMAH SAKIT UMUM DAERAH BESUKI

Mulia, Alvira Nafisah Eky (2022) ANALISIS PENGELOLAAN DOKUMEN REKAM MEDIS RAWAT INAP BAGIAN ASSEMBLING DI RUMAH SAKIT UMUM DAERAH BESUKI. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Medical record management is an activity carried out to document and maintain medical records properly. Based on a pre-interview research, there are medical record documents that do not match the order 82%, late returns 73%, incomplete integrated patient progress notes 61% and incomplete medical resumes 73%. The purpose of this study was to analyze the management of inpatient medical record documents at the assembling section at the Besuki Regional General Hospital with motivation, opportunity and ability variables. This research used a qualitative method with data collection techniques interview, observation, documentation, USG and brainstorming. The subjects in this study were 1 head of medical records and 5 assembling officers.The results showed that the priority problems that must be resolved first were assembling officer had never attended any training, the SOP for assembling was lost and had never been socialized to assembling officer and there was no use of incomplete record cards. The alternative problem solving is hold training related to assembling medical record documents, redesigning the SOP for assembling and disseminate SOP to all medical record officers, especially assembling and designing incomplete record cards. The conclusion related to the factors causing the problem from the motivation variable is that there is still no award and punishment for the medical record officer in the assembling section. Opportunity variables are the absence of incomplete record cards, assembling officers have never attended any training, the assembly SOP is missing and has never been socialized. The ability variable is that there are assembling officers who do not have a minimum education of D3 Medical Record, the knowledge of assembling officers is still lacking and there are officers who have work experience of less than 2 years.

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