Analisis Faktor Penyebab Ketidaklengkapan Pengisian Laporan Operasi Kasus Bedah Obgyn Pasien Rawat Inap Di Rsud Dr. Abdoer Rahem Situbondo

Andini, Andini (2023) Analisis Faktor Penyebab Ketidaklengkapan Pengisian Laporan Operasi Kasus Bedah Obgyn Pasien Rawat Inap Di Rsud Dr. Abdoer Rahem Situbondo. Diploma thesis, Politeknik Negeri Jember.

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Abstract

Obgyn surgery reports are reports or notes regarding surgical procedures for patients. Completion of Operational Obgyn Surgery report for Inpatients at RSUD dr. Abdoer Rahem Situbondo hasn’t reached 100%. Based on a preeliminary study research, the percentage of incompleteness is found in the identification component by 27%, important reports by 40% and authentication by 33%. This can result in unclear procedure sequences, pending claims, and has an impact on the quality of inpatient medical records. The purpose of this study was to analyze the factors causing the incompleteness in filling out the obgyn surgery reports for inpatients at RSUD dr. Abdoer Rahem Situbondo. This research used a qualitative method with data collection techniques interview, observation, documentation, and discusiion. The subjects of this study were 2 obgyn doctors, 1 nurse of central surgery, chief of obgyn departement, and chief of medical records. The results in this study show that the cause of incomplete filling are as follow: the officers who lacked discipline and responsibility in filling out obgyn surgery reports, there are no records of incomplete filling, there are no reward and punishment given to officers, less detailed SOP and there are no socialization of SOP. The solution to solve this problem are as follow: to implement reward and punishment so that officers can be more disciplined, to make notes on incompleteness, to improve the SOP for filling out surgery reports and to conduct socialization of SOP for filling out surgery reports. Keywords: Hospital, Incompleteness, Obgyn Surgery Report

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