Analisis Faktor Penyebab Ketidaklengkapan Pengisian Berkas Rekam Medis Rawat Jalan Di Puskesmas Bluto Kabupaten Sumenep

Rochim, Nur An Nisyah (2022) Analisis Faktor Penyebab Ketidaklengkapan Pengisian Berkas Rekam Medis Rawat Jalan Di Puskesmas Bluto Kabupaten Sumenep. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Based on the results of observations at the Bluto Public Health Center, it is known that there was an incompleteness of outpatient medical records with a percentage of 8.2% with the number of medical records that are not completely filled as many as 22 files from 267 files. This study aims to analyze the factors causing the incompleteness of outpatient medical records at the Bluto Public Health Center based on Gibson's performance theory, namely individual factors, organizational factors, and psychological factors by prioritizing problems using the Urgency, Seriousness, Growth (USG) method and improvement efforts through brainstorming. This type of research was qualitative research with data collection methods through interview, observation, documentation, and brainstorming. The results of the study were based on individual factors, namely the experience of medical officers who were still short and most medical officers have never attended training on medical records. Organizational factors, namely there was no control card, obstacles to computer networks, the implementation of Standard Operating Procedures (SOP) that were not optimal, and officers had many responsibilities beyond the main duties in the job description. Psychological factors, namely that there were no punishment for officers who were not complete in filling out the medical records and the officer's lack of accuracy when filled out the outpatient medical record. As for efforts to solved the problem, the medical officers can routinely re-check the completeness of the medical records before it returns to the Medical Record Unit, conduct guidance and training to improve the skills of officers, reduce the use of facilities with high electrical power, plan the budget for repairing electrical installations, routine socialization of Standard Operating Procedures (SOP) and the provision of Standard Operating Procedures (SOP) in each room in the service unit.

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