Analisis Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Pasien Rawat Inap di Puskesmas Umbulsari Jember

Sari, Dwi Navida (2023) Analisis Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Pasien Rawat Inap di Puskesmas Umbulsari Jember. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

The completeness of medical record filling is very important so that it can have an impact on the quality of medical records and health services. Based on a preliminary study, filling out inpatient medical records at the Umbulsari Jember Health Center was still incomplete in June-August 2022 with an incomplete percentage in June of 6.70%, July of 8.92%, and August of 7.72 %. Incomplete medical records have an impact that causes the workload of medical record officers in data processing to increase, inpatient medical records cannot be entered into the medical record storage room, and reports on the completeness of medical record filling are hampered. This study aims to analyze the factors causing incomplete medical record filling of inpatients at the Umbulsari Jember Health Center. The type of research used in this study used qualitative data collection techniques, namely observation, in-depth interviews, documentation, ultrasound, and brainstorming. The subjects of this study were 1 head of puskesmas, 1 doctor, 2 inpatient nurses, and 1 medical record officer. The object of research is the medical records of inpatients. The results showed that the cause of the incompleteness of the motivation factor was the absence of rewards for officers who filled out the inpatient medical records. The opportunity factor is that there has never been training related to filling out medical records, there is no SOP for filling out medical records, there has never been socialization of SOPs for evaluating the completeness of medical records. The ability factor is the lack of knowledge of officers and the presence of officers with a new working period who are still in the environmental adjustment stage. The results of the problem priority obtained are that there is no SOP for filling in medical records. The efforts to fix the problem are making and socializing the SOP for filling in medical records.

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