Analisis Kualitatif Medis Rekam Medis Rawat Inap Pasien Dengue Haemorrage Fever (A91) di RSU Dr. H. Koesnadi Bondowoso Tahun 2017

Wulandari, Nuraini (2019) Analisis Kualitatif Medis Rekam Medis Rawat Inap Pasien Dengue Haemorrage Fever (A91) di RSU Dr. H. Koesnadi Bondowoso Tahun 2017. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Medical qualitative analysis is the analysis of data completeness or information in order to realize medical services quality. Dr. H. Koesnadi Bondowoso general hospital has never conducted a medical qualitative analysis of medical record documents for inpatient of dengue haemorrage fever (A91) cases and still found lack of completeness and utilization of medical information on dengue haemorrage fever (A91). In the preliminary study, there were incompleteness of data filling for aspects of history (100%), physical examination (100%), supporting examination (10%), therapy or treatment (100%), and education (0%). This research aims to analysis the medical records quality of inpatient dengue haemorrage fever (A91) cases at Dr. H. Koesnadi Bondowoso general hospital in 2017. It is a qualitative research, data were collected by observation and interview. The results of anamnesa found 98% fever, 80% pain, 79% nausea, 79% appetite, 5% reddish spots, 33% bleeding manifestations. The results of physical examination found 99% general condition, 95% patient awareness, 98% vital signs, 90% hepatomegaly, 97% ascites. Extra information on hemactocrit and platelet 98%. Therapy information Infusion of 97%, nutritional support 96%, symptomatic 97%. Educational information 97%. Completeness of medical information on dengue haemorrage fever (A91) medical record documents at Dr. H. Koesnadi Bondowoso general hospital is still not done optimally. Nurses and doctors should work together to check the completeness of medical records documents.

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