Analisis Ketidaklengkapan Pengisian Resume Medis Rawat Inap RSD Balung

Anggraini, Chintya Dini (2024) Analisis Ketidaklengkapan Pengisian Resume Medis Rawat Inap RSD Balung. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Medical resume is a summary of all important information given to patients from the time they are admitted to the hospital until they are discharged and used as a basis for further action. The completeness of the medical resume reflects the quality of the patient's medical records. The results of a preliminary study at Balung Hospital found that 81.2% of the medical resumes were incomplete. The purpose of this study was to analyze the incompleteness of the medical resume at Balung Hospital. This type of research is qualitative. The subjects in the study consisted of 2 DPJPs, 2 heads of inpatient rooms, 1 head of medical records, and 1 assembly officer. Data collection techniques used interviews, observations, and documentation. The incompleteness of the medical resume was caused by the lack of training in filling out the medical resume, the socialization was also not attended by the DPJP, the absence of SOPs for filling out medical resumes and the DPJP's ignorance of the guidelines for filling out medical resumes caused the medical resumes to be incomplete according to the predetermined standards, monitoring was not carried out periodically by the leadership so that they could not find out the development of the DPJP's performance. The suggestion in this study is to provide direct socialization to DPJP in carrying out the process of filling out medical resumes, holding special training for filling out medical resumes such as in-house training, conducting monitoring and evaluation periodically and consistently and providing special SOPs for filling out medical resumes.

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