ANALISIS FAKTOR PENYEBAB KETIDAKLENGKAPAN PENGISIAN REKAM MEDIS RAWAT JALAN DI PUSKESMAS SERIRIT II

Shamila, Kavin Akmaliah Rizky (2023) ANALISIS FAKTOR PENYEBAB KETIDAKLENGKAPAN PENGISIAN REKAM MEDIS RAWAT JALAN DI PUSKESMAS SERIRIT II. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

The completeness of outpatient medical records documentation is crucial because it concerns patients’ medical data. Based on the preliminary studies, it as known that the incompleteness of outpatient medical records documentation is at a percentage of 49.2% with 118 files out of 240 files found to be incomplete. This research aimed to analyze the factors causing incompleteness of outpatient medical record documentation at Public Health Center (PHC) of Seririt II with Lawrence Green and World Health Organization behavioral theory, including predisposing, enabling, and reinforcing factors. This study used qualitative research approach. The subjects consisted of the head of the PHC, head of medical records, dentist, dental nurse, general practitioner, nurse, and midwife. Data collection methods used interview, observation, documentation and group discussion. The results of this research indicate that the factors that cause incompleteness outpatient medical records are predisposing factors indicate a lack of staff knowledge regarding the standard time for completing outpatient medical records, the enabling factor, training has never been held related to medical record management due to insufficient budget allocation, and the reinforcing factor, socialization has not been carried out to all staff and in the SOP outpatient medical record there is no standard time for completing outpatient medical record. The solutions to this issues include the head of PHC conducts training or socialization in outpatient medical record, the head of PHC should also make efforts to manage finances to ensure the implementation of training on medical records management, the medical record staff should conduct socialization on the SOP to all staff who fill in medical records and revise the SOP for outpatient medical record documentation.

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