Analisis Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Rawat Jalan di Puskesmas Panji Kabupaten Situbondo

Fardayansyah, Anil (2023) Analisis Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Rawat Jalan di Puskesmas Panji Kabupaten Situbondo. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Incomplete filling of medical record files often occurs, one of which is at the Panji Primary Health Center. The number of incomplete filling out of outpatient files at Public Medicine centers was very high with the total percentage of incompleteness in March, April and May reaching 29.1%, and tends to increase every month. The purpose of this study was to analyze the causes of the incomplete filling out of outpatient medical record files at the Panji Primary Health Center based on Armstrong and Baron's performance theory. This research used qualitative with observational data collection techniques, in-depth interviews, documentation, and brainstorming. The subjects of this study were 2 medical record officers, 1 person in charge of the medical record, 2 doctors, and 1 person in charge of quality. The results in this study were individual factors, consisted of lack of knowledge of officers, never attended training, and lack of commitment by officers to fill out and complete medical records ≤ 24 hours after completion of service. The leadership factor was the absence of guidance and giving rewards to medical record officers. Team factor was not a factor causing incomplete outpatient medical records at Panji Primary Health Center. The system factor was that there has never been socialization of standard operational procedures for filling in the medical record and standard operational procedures for assessing the completeness of medical record files. The situational factor was the existence of officers who work not in accordance with the job description or double job. The alternative solution to solving this problem is by holding workshops and training for medical record unit officers and doctors regarding medical records, as well as socializing the standard operational procedures for Filling in Medical Records and standard operational procedures for Assessment of Completeness of Medical Records.

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