Analisis Faktor Penyebab Ketidaklengkapan Resume Medis Pasien Rawat Inap di Puskesmas Sukosari Bondowoso

Madani, Vita (2023) Analisis Faktor Penyebab Ketidaklengkapan Resume Medis Pasien Rawat Inap di Puskesmas Sukosari Bondowoso. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

The achievement of filling out inpatient medical resumes at the Sukosari Bondowoso Community Health Center is less than the completeness standard, namely 100% filled. Based on preliminary studies, researchers know that the largest incompleteness rate in filling out inpatient medical resumes is in the patient identification item, namely 30%, and the smallest amount of incompleteness in filling out inpatient medical resumes is in the record validity item, namely 3%. This study aims to analyze the factors causing incomplete inpatient medical resumes at the Sukosari Bondowoso Community Health Center. The type of research used is qualitative with data collection techniques, namely interviews, observation and documentation, using ultrasound to determine problem priorities and improvement efforts using brainstorming. Research subjects included 1 doctor, 3 nurses and 1 medical records officer. The method used is the 5M management element. The results of research on the human element, namely the educational qualifications of medical record officers, are still not in accordance with statutory regulations. The element of money is not a factor causing an incomplete medical resume. The material element is that there are the same items on the medical resume. The machine element is an inadequate medical record shelf. The method element is that there is no SOP regarding filling out and completeness and accuracy of the contents of medical records. Based on the ultrasound results, 3 priority problems were obtained, namely that there were the same items on the medical resume form, the medical record shelf was inadequate, the educational qualifications of medical record officers were still not in accordance with statutory regulations. Efforts to correct the problem include redesigning the medical resume form, routinely sorting active and inactive files, placing officers according to their training.

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