Analisis Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Rawat Jalan Di RSU Bhakti Husada Krikilan Banyuwangi

Cantika, Diska (2023) Analisis Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Rawat Jalan Di RSU Bhakti Husada Krikilan Banyuwangi. Undergraduate thesis, Politekni Negeri Jember.

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Abstract

Incomplete filling of medical records often occurs, outpatient medical record Bhakti Husada Krikilan Banyuwangi Hospital. The number of incomplete medical records outpatient at Bhakti Husada Krikilan Banyuwangi Hospital was high, with percentages in April at 40%, May at 41%, and June at 52%. The purpose of this study was to analyze the factors causing the incomplete outpatient medical records at Bhakti Husada Krikilan Banyuwangi Hospital based on Lawrance Green's theory. The type of research used qualitative. The data querecollected by observational data collection techniques, in-depth interviews, documentation, scoring, and brainstorming. The subjects of this study were one head of medical records, one assembling officer, three doctors, and six nurses. The object of study was an outpatient medical record. Secondary data was obtained from the incompleteness of medical records. The results in this study were predisposing factors, of incomplete lack of officer knowledge, lack of officer attitude, lack of training, and officer indiscipline in filling out medical records. Enabling factors was no budget for training. Reinforcing factors were no reward, less optimal punishment, and no Standard Operational Procedure (SOP). The result of the priority problems obtained were absence of SOP, no training, and lack of officer knowledge. The efforts to fix the problem are creating and socializing SOP of medical records, filling conducting internal training, and reminding each other of the medical record filing officers.

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