Analisis Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Rawat Inap di RSUD Arifin Achmad Provinsi Riau

Nasution, Nurlia Susanti (2024) Analisis Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Rawat Inap di RSUD Arifin Achmad Provinsi Riau. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

A complete medical record is a medical record that has been filled out 100% by the Professional Care Provider ≤ 24 hours after the patient gets discharged. The highest percentage of incomplete inpatient medical records at RSUD Arifin Achmad in Riau Province in the third quarter of 2022 occurred in October 2022, with 465 medical records (32.68%). This study aimed to analyze the factors causing incomplete inpatient medical records at RSUD Arifin Achmad in Riau Province using Lawrence Green's behavioral theory based on predisposing, enabling, and reinforcing aspects. The type of research was qualitative, with data collection techniques including observation, documentation, interviews, and brainstorming. The study revealed that predisposing factors included a lack of staff knowledge regarding medical record filling. Enabling factors were the insufficient number of computers, medical record filling training not being attended by all staff, the absence of a rewards system, and some staff being unaware of the Standard Operating Procedure (SOP) for complete medical records. Reinforcing factors included the non-implementation of punishments. Improvement efforts included conducting socialization, monitoring, and evaluation of the SOP for completed medical records; organizing periodic training sessions to familiarize medical personnel and medical record officers with the SOP for maintaining complete medical records; and implementing a reward and punishment system based on medical personnel's performance in filling out inpatient medical records.

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