Analisis Kuantitatif dan Kualitatif Berkas Rekam Medis Rawat Inap Pasien Gastroenteritis Acute Anak di RS Umum Wonolangan Probolinggo Tahun 2018

Kulsum, Ummy (2019) Analisis Kuantitatif dan Kualitatif Berkas Rekam Medis Rawat Inap Pasien Gastroenteritis Acute Anak di RS Umum Wonolangan Probolinggo Tahun 2018. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Analysis quality of medical record consist of quantitative analysis, administrative and medical qualitative analysis. The research subjects was 1 pediatrician, 2 nurses, 1 leader of medical record. Research object was 44 files of acute gastroenteritis patients in first quarter of 2018. The type of qualitative research by the technique of collecting data observation and interview. This study reveal that found 2% incompleteness in the signature of approval, signature of the officer 11%, and 7% of the corrective action not appropriate to the rules. Variable clarity of problem and condition or diagnosis, 20% of patients diarrhea with frequency of diarrhea ≤ 3 times given ORS fluids and 11% of patients without fever were given antipyretic. The input variable is 100% consistent with supporting data. Variable service reasons were not appropriate, 36% treatment of antibiotics in patient non dysentery and 7% treatment of ringer lactate fluid in patient not severely dehidration. Use of informed consent was 100% appropriate for specific medical action in GEA patient. The variable is 7% recording with the condition that the writing is unreadable. Variable anamnesa 91% with a description of feces consistency, 75% with information on mucus blood in the feces, information frequency of diarhea 93%, diarrhea duration 73%, 64% information on fever patients. Physical examination variable was 54% without a description the degree of dehydration. 2% therapy variable treatment of ORS is not appropriate with dehydration patient. The variable patient's condition returned without information about consistency of feces 30% and frequency of diarrhea 16%.

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