Analisis Faktor Penyebab Ketidaklengkapan Pengisian Dokumen Rekam Medis Pasien Rawat Inap di Puskesmas Kademangan Bondowoso

Afifar, Muhammad Danang (2020) Analisis Faktor Penyebab Ketidaklengkapan Pengisian Dokumen Rekam Medis Pasien Rawat Inap di Puskesmas Kademangan Bondowoso. Undergraduate thesis, POLITEKIK NEGERI JEMBER.

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Abstract

The implementation activities of medical records in Puskesmas Kademangan Bondowoso is still not optimal. This can be seen from the assembling activities still have not done, so it causing incompleteness in filling documents. Incomplete filling out documents can cause reduced a quality of service. This research was aimed to analyzed the factors that causing incomplete filling of medical record document in Kademangan Public Health Centers. The type of this research was qualtative research. Collecting data was using interview, observation, documentation and quistionnare. The research subject has amount 6 peoples consist of 2 medical records officer, a doctor, a nutrisionist and 2 nurses, one as a head of hospitalization in Kademangan Health Centers. The research result showed causes of the incompleteness is not having provided training in organizing medical records, medical training officers with a long tenure did not have filled medical record completely, a lack of responsibility, unavailability of pharmaceutical officers was took for responsible filling pharmaceutical sheets, filling documents out according to SOP, there’s not the socialization sop of completeness, the arrangements of nutritional care form that has not been systematic, monitoring and supervision has never been carried out, lack of discipline of officers in filling medical record documents and not the implementation provision of reward and punishment to officers to increase the motivation in filling documents medical records. The efforts to resolve the problems obtained by using brainstorming include conducting medical record training, redesigning nutritional care forms, socializing SOPs for completing medical record documents, recruiting members including pharmacy officers, conducting monitoring and supervision activities for filling medical record documents, providing punishment and reward to officers who fill out complete medical record documents.

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