Analisis Faktor Penyebab Ketidaklengkapan Rekam Medis Rawat Jalan Di Puskesmas Dongko Trenggalek

Fharelya, Devanda (2023) Analisis Faktor Penyebab Ketidaklengkapan Rekam Medis Rawat Jalan Di Puskesmas Dongko Trenggalek. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

The number of incomplete outpatient medical records at Dongko Trenggalek Health Center based on checklist sheest in January - July 2022 reached 51% of a total of 2515 files. It did not meet the standards set by the Ministry of Health which had to be 100% complete. The purpose of this study was to analyze the causing factors of incomplete outpatient medical records at Dongko Trenggalek Health Center. This type of research was qualitative data were collected using interview, observation, documentation,problem priority was done by CARL(Capability, Accesibility, Readines, and Laverage) and brainstorming. The research subjects consist of 3 doctors, 1 midwife, 2 nurses and 2 medical record officesr. The variables were predisposing, enabling, and reinforcing factors. The results presents the causing factors of incomplete outpatient medical records due to the lack of knowledge of officers regarding the completeness of outpatient medical records, the contents of the SOP of medical record filling was incomplete,the contents of the SOP was not in accordance with theory, no reward or punishment and the implementation medical record filling was not accordance with SOP. The problem priority illustrates that there was the lack of staff’s knowledge related to terms, standards, and conditions of incomplete medical records. Moreover there was no standard in the SOP of medical record completeness medical record filling and good filling method. The suggestions are the medical record officers need to improve the SOP and generate internal training to the staff’s who involved the medical record filling.

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