Strategi Pendukung Kelengkapan Pengisian Elektronik Medical Record Rawat Inap Dan Rawat Jalan Di RS PHC Surabaya

Ilmia, Hidayatul (2022) Strategi Pendukung Kelengkapan Pengisian Elektronik Medical Record Rawat Inap Dan Rawat Jalan Di RS PHC Surabaya. Project Report. Politeknik Negeri Jember, Jember. (Submitted)

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Abstract

Hospital is a health service institution that provides complete individual health services that provide inpatient, outpatient, and emergency services. One of the service units that need to be improved in hospitals is the medical record work unit. Organizing medical records is a factor that determines the good or bad service in the hospital. The rapid advancement of technology in the current era of globalization in the health sector, especially in the medical record unit, hospitals are required to follow the development of modern technology in providing services, encouraging hospitals in developing countries including Indonesia to start implementing the use of Electronic Medical Records. (EMR) as a substitute for paper-based medical records following developed countries that have used them first (Pratama & Darnoto, 2017). Service quality is very important to maintain the existence of a hospital (Lubis, 2009). The good or bad of a service is described by whether or not the medical record file in a hospital is complete (Alif, 2019). Completeness of EMR is important because it affects the quality of hospital services, incomplete information data filling can have an impact on the quality of EMR and services provided by hospitals so that it can trigger problems in the future (Pratama & Darnoto, 2017). The problem that often occurs in the medical record unit at PHC Surabaya Hospital is the incomplete filling of the inpatient EMR so that an inpatient EMR revision must be carried out to the PPA (Care Service Provider) or related room. Officers also find it difficult to monitor the evaluation of the completeness and incompleteness of the EMR so that it has an impact on work delays. Officers also find it difficult to report the results of monitoring and evaluation to the leadership or superiors because they do not have incomplete data that must be processed every day. In the medical record unit there is also no review of completeness and incompleteness, so that officers find it difficult to determine progress. The purpose of this study is to provide suggestions related to "Strategies to Support the Completeness of Inpatient EMR Filling at PHC Hospital Surabaya" using qualitative methods by direct observation at PHC Surabaya Hospital.

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