Analisis Ketidaklengkapan Pengisian Formulir Catatan Keperawatan Dan Kebidanan Rawat Jalan Di Puskesmas Banyuputih Situbondo

Ally, Maria Emilia (2023) Analisis Ketidaklengkapan Pengisian Formulir Catatan Keperawatan Dan Kebidanan Rawat Jalan Di Puskesmas Banyuputih Situbondo. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

The completeness of the nursing and midwifery record form after service must be 100%. Based on preliminary studies at Banyuputih Situbondo Health Center, it was found that the number of incomplete Nursing and Midwifery Record Forms in April - June were 946 forms with a percentage of 29.7%. The purpose of this study was to analyze the incomplete of outpatient nursing and midwifery record forms at the Banyuputih Situbondo Health Center. This type of research was qualitative with data collection by in deep interview, observation, kuisioner and documentation. The research subjects were the Head of Banyuputih Health Center, 1 Medical Record Officer, 3 Nurses, and 3 Midwives. The object of the research was all nursing and midwifery record forms. During observation, it was found was found that the incompleteness of it were 66.7% of 30 forms. The highest incompleteness was in the important reporting component. The results of the analysis found that incompleteness occurred due to predisposing factors, i.e., the lack of knowledge of nurses and midwives regarding completeness standards, attitudes of nurses and midwives who lack a sense of responsibility for filling out forms, while enabling factors, namely ballpoint supplies were always available, and the completeness checklist had been used properly by medical record officers. Reinforcing factors were no awards and strict sanctions against medical personnel and socialization of standard operational procedures that were still less effective and less detailed content. Suggestions that can be proposed are improving standard operational procedures, conducting intensive socialization of filling out medical records and providing them to related units, providing optimal socialization and evaluation of the importance of filling out medical records and the latest medical record regulations, giving awards according to the wishes of officers in the form of gifts according to the wishes of the head of the health center, giving strict sanctions in the form of giving warning letters. Keywords: Nursing and midwifery records, forms, incompleteness

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