Analisis Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Pasien Rawat Jalan di Puskesmas Bangil

Mumtaza, Jihan Ghina (2023) Analisis Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Pasien Rawat Jalan di Puskesmas Bangil. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Incomplete medical record filling can affect the quality and process of services provided to patients. Based on a preliminary study at the Bangil Health Center, it is known that in January–March 2022, 880 out of 6708 outpatient medical records were found to be incomplete, for an incomplete percentage of 12.73%. The highest level of incompleteness was found in communication, information, education data items and initials. This incompleteness has an impact on delays in returning medical records. The purpose of this study was to analyze the factors causing incomplete medical record filling for outpatients at the Bangil Health Center based on the 5M theory. This qualitative research uses data collection methods such as interviews, observation, and documentation. Prioritization of problems using the USG method and preparation of recommendation efforts using the brainstorming method The results showed that the cause of incompleteness in the man factor was the lack of knowledge of nurses regarding the standard percentage for completeness of medical records and the fact that they had never been trained to support the completeness of medical records. In the method factor, there is no SOP for filling out medical records. In the money factor, there is no budget available for internal training due to limited funds for the medical record unit. Efforts to fix the problem include increasing the knowledge of nurses through the dissemination of the completeness of medical records, compiling SOPs for filling out medical records, and planning internal training activities to support the completeness of medical records.

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