Analisis Faktor Penyebab Ketidaklengkapan Rekam Medis Rawat Inap di Puskesmas Jelbuk

Lafissyah, Holida (2023) Analisis Faktor Penyebab Ketidaklengkapan Rekam Medis Rawat Inap di Puskesmas Jelbuk. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

The accomplishment of completing inpatient medical records at the Jelbuk Public Health Center amounted to an average of 18.9% in February, 15.5% in March, and 26.1% in April, less than the completeness target of 100%. The purpose of this study was to analyze the factors causing the incomplete filling of inpatient medical records at the Jelbuk Public Health Center based on individual, organizational, and psychological factors. A qualitative type of research was used with 5 research subjects consisting of 1 head of the public health center, 1 doctor, 2 nurses, and 1 medical recorder. The data collection technique used interviews, observation, documentation, USG, and brainstorming. The results showed that inpatient medical records were incomplete due to the lack of knowledge of medical recorders regarding filling in due to the absence of SOPs for filling out medical records, medical recorders were not able and skilled in filling out medical record forms, educational qualifications did not fulfill the established standards, had never attended training in filling out medical records. The lack of health workers on duty in the inpatient unit, there was no follow-up after evaluating incomplete inpatient medical records, and rewards and punishments were never being applied as a form of work motivation in filling out medical records. Based on the order of priority using USG, the resulting 3 priority problems include the lack of training in filling out medical records, the lack of health workers for service needs in the inpatient unit, and educational qualifications that do not meet predetermined standards. The attempts to fix these problems include applying for training in filling out medical records to the health office, providing job vacancies by submitting requests for medical personnel to the health office related to the position of doctors or nurses, and submitting requests for medical record clerks to the health office

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