Faktor Penyebab Ketidaklengkapan Pengisian Berkas Rekam Medis Pasien Rawat Inap

Putri, Angga Kristiana and Nurmawati, Ida and Santi, Maya Weka and Swari, Selvia Juwita (2022) Faktor Penyebab Ketidaklengkapan Pengisian Berkas Rekam Medis Pasien Rawat Inap. Jurnal Penelitian Kesehatan" SUARA FORIKES"(Journal of Health Research" Forikes Voice"), 13 (4). pp. 894-901. ISSN 2502-7778

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Abstract

Incomplete medical records have an impact on the low quality of medical records and health services. The purpose of this study is to analyze the factors that cause incomplete filling in medical record files for inpatients at the hospital based on the 5M elements of management (Man, Money, Methods, Machine, Material). This study was a literature review. The results of the analysis showed that incomplete medical record files were 34.3%. Many of the items that were not filled in completely from the medical record form included authentication from doctors and nurses, namely 7 articles. Factors causing incomplete filling of inpatient medical record files with the highest percentage were lack of knowledge of staff, lack of budget, lack of rewards and punishments, non-specific or incomplete checklists for assessing file completeness, and medical record files that were less systematic. Efforts that need to be made are increasing the knowledge of officers about the importance of completing medical record files, implementing a reward and punishment system to motivate officers, improving checklist sheets and medical record files according to standards.

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