Analisis Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Rawat Inap di RSI Fatimah Banyuwangi

Febrianti, Linda Dwi (2023) Analisis Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Rawat Inap di RSI Fatimah Banyuwangi. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Medical records are said to be of good quality if the data or information from medical records is good and complete. The standard for completeness of filling out medical records 24 hours after service is 100%. Based on preliminary studies of the completeness of filling out medical records 24 hours after service in January - March 2022, the results were January 2022 (68.95%), February 2022 (77.81%), and March 2022 (68.32%). The impact of incomplete filling of medical records is that the quality of medical records will be disrupted because the data in the patient's medical record is not appropriate. The purpose of this study was to analyze the factors causing incomplete filling of inpatient medical records at RSI Fatimah Banyuwangi with Robbins' performance theory which consists of motivation, opportunity, and ability variables. The type of research used is qualitative with data collection techniques in-depth interviews, observation, documentation, and brainstorming. The research subjects consisted of 3 doctors, 3 nurses, and 3 medical record officers. The results of the study based on the prioritization of problems with ultrasound obtained causes, namely the large number of forms and fields that must be filled in while doctors and nurses also provide services to patients, the lack of strict punishment for officers who do not fill out medical records completely, and the lack of knowledge of doctors and nurses regarding filling out medical records. The efforts to fix the problems obtained are increasing the discipline of doctors and nurses, changing the internal report system for the completeness of medical records to a daily system by giving strict punishment to officers if they do not fill in completely, and intensifying the In House Training program for filling out medical records regularly so that the knowledge of doctors and nurses is getting better.

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