Analisis Kuantitatif Rekam Medis Rawat Inap Di Rumah Sakit: Literature Review

Yumna, ‘Athiyyah (2022) Analisis Kuantitatif Rekam Medis Rawat Inap Di Rumah Sakit: Literature Review. Diploma thesis, Politeknik Negeri Jember.

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Abstract

The implementation of recording and documenting medical record in hospital is still not carried out optimally. This can be seen from the number of medical record that are not filled out correctly so that the information contained in them is not complete and accurate. The incomplete filling of this medical record can lead to reduced service quality. This research aims to analyze quantitatively the completeness of the medical record of inpatients in hospitals. The method used in this research is a literature review. The object of research is 19 articles with the same theme as this research. The results of the research indicate that the completeness of the medical record in health care facilities has not reached the standard set by the government, which is 100% complete. Many components of the completeness of patient data are not filled in where the lowest completeness of the patient identity component reaches 1.72%. The lowest completeness of the authentication component reaches 31%. The lowest completeness of the important reporting components reached 44.9%. And the lowest completeness of the correct documentation component reaches 0%. Hospitals need to carry out quantitative analysis of medical record on a regular basis in order to improve the quality of the data in the medical record, make or review SOPs related to quantitative analysis in health care facilities, as well as apply a reward and punishment system to all medical record officers. Keywords: Quantitative Analysis, Inpatient, Medical Record, Literature Review

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