Analisis Kelengkapan Rekam Medis Berdasarkan Elemen PenilaianAkreditasi SNARS di Rumah Sakit Umum Purwogondo Kebumen

Abidin, Afrizal Noor (2022) Analisis Kelengkapan Rekam Medis Berdasarkan Elemen PenilaianAkreditasi SNARS di Rumah Sakit Umum Purwogondo Kebumen. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

The hospital is a health service institution that provides complete individual health services that provide inpatient, outpatient, and emergency services. Oneof the quality of the hospital is determined by a complete medical record document. The completeness of medical records at the Purwogondo General Hospital inKebumen only reached 86% of the 100% standard specified in the minimumservice of the medical record unit. Maximum completeness of medical records isneeded so that the function of medical records can be realized. One of thefunctions of a complete medical record is the creation of continuity of treatment for patients and also that medical records have strong legal force in the event of an undesirable event during the patient's treatment period. The importance of theexistence of medical records, the completeness of 100%medical records isabsolutely necessary. The subjects of this study were 6 employees consistingof doctors, nurses, representatives from the quality team, medical recorders, internal supervisors, MIRM working group of icers. Data collection methods that researchers use are observation, interviews and brainstorming. The results of theresearch on man elements related to optimizing the completeness of medical records are of icer discipline and communication. The money element is theabsence of a budget for the monitoring and evaluation team. The method element is the absence of an SOP for reviewing the completeness of medical records. Thematerial element is the design of the form that has not been understood by the cargiver. The machine element is the absence of an incomplete medical recordcontrol book and no monitoring and evaluation team for the completeness of themedical record. Ef orts to optimize the completeness of medical records aremonitoring medical records on a regular basis and optimizing the monitoringandevaluation team.

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