Analisis Kualitatif Medis Dokumen Rekam Medis Rawat Inap Pasien Sectio Caesarea di RSU Kaliwates Jember

Oktavia, Maharani Pandu (2024) Analisis Kualitatif Medis Dokumen Rekam Medis Rawat Inap Pasien Sectio Caesarea di RSU Kaliwates Jember. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Qualitative medical analysis is an activity of analyzing medical records that aims to determine the extent of the quality of medical services provided to patients based on the use of complete medical information, especially for patients with caesarean section deliveries. The form of problem that usually occurs is the increase in the number of Sectio Caesarean sections that exceed WHO standards. This study aims to analyze the medical qualitative documents of inpatient medical records of caesarean section patients at Kaliwates Hospital, Jember. Observational descriptive quantitative research was conducted by conducting observations on 117 medical record documents (DRM) of caesarean section patients at Kaliwates Hospital, Jember. The data obtained were analyzed using descriptive statistical techniques and score categorization with cross-tabulation data presentation techniques. The results of the study showed that the incompleteness of extra narrow pelvis information was 100% (117 DRM), incompleteness of extra CPD information was 100% (117 DRM), incompleteness of extra imminent uterine rupture information was 100% (117 DRM), incompleteness of extra placenta previa information was 98% (115 DRM), incompleteness of extra cervical/vaginal stenosis information was 100% (117 DRM), incompleteness of extra tumors of yhe birth canal causing obstruction information was 97% (114 DRM), incompleteness of extra fetal malposition information was 92% (108 DRM), incompleteness of extra fetal distress information was 100% (117 DRM) and incompleteness of extra fetal congenital abnormalities information was 100% (117 DRM). Thus, there needs to be an improvement in the implementation of patient observation through updating the clinical practice guidelines for the management of obstetric and gynecological KSM cases of caesarean section delivery at Kaliwates Hospital, Jember.

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