Analisis Ketidaklengkapan Pengisian Informed Consent Rawat Inap di Rumah Sakit Umum Kaliwates

Cantika, Chiara Pramudya (2025) Analisis Ketidaklengkapan Pengisian Informed Consent Rawat Inap di Rumah Sakit Umum Kaliwates. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Incompleteness Patient identification filling on medical record document forms is important to determine ownership of the documents and forms. Incompletes of patient identification filling at Kaliwates General Hospital have an impact on the low quality of medical records because medical records do not contain complete information. Based on a preliminary study of the incompleteness of informed consent sheets in 50 medical record documents, the completeness of informed consent filling was not 100%. This study aims to analyze the factors causing incompleteness of informed consent filling in medical record documents at Kaliwates General Hospital based on the 5M management elements, namely man, money, material, machine, and method. This type of research is qualitative. The data collection method in this study was observation, interview, documentation, and discussion. The results of this study, namely starting from the 5M stage, namely efforts to improve the filling of informed consent for surgical patients, obtained steps or solutions that can be taken, namely by conducting socialization evenly to all officers related to filling out informed consent and making SOPs (Standard Operating Procedures) for filling out informed consent at Kaliwates General Hospital. The conclusion of the study that is a factor causing incomplete patient identity is the variable man, money, and method. The efforts to improve the problem are that the hospital provides seminar training to officers, conducts monitoring and evaluation of incomplete filling of informed consent routinely, creates Standard Operating Procedures and conducts socialization of Standard Operating Procedures related to filling out medical records, and budgets for training for officers.

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