Analisis Kualitatif Dokumen Rekam Medis Rawat Inap Pada Pasien Diabetes Melitus Tahap II Di PT. Rolas Nusantara Medika Rumah Sakit Umum Kaliwates Tahun 2015

SARI, ERINDA RETA (2016) Analisis Kualitatif Dokumen Rekam Medis Rawat Inap Pada Pasien Diabetes Melitus Tahap II Di PT. Rolas Nusantara Medika Rumah Sakit Umum Kaliwates Tahun 2015. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

The completeness of medical record document highly affects information that is generated that medical record document. We often find the incompleteness of medical record fulfillment in PT. Rolas Nusantara Medika RSU Kaliwates. The purpose of this research is to analyze of medical record document diabetes melitus type II in PT. Rolas Nusantara Medika RSU Kaliwates on 2015 with qualitative analysis method. This research uses qualitative method and collect data by observation, interview, analyze of medical record document diabetes melitus type II disease that has been filled. The object of this research is 114 medical recors documents diabetes melitus type II disease on 2015. The result of incompleteness In qualitative way in each review show that completeness and diagnosis consistency review from 114 document 13 incomplete and 33 inconsistent, completeness and consistency reporting diagnosis review 33 incomplete and inconsistent, reporting on things are done during treatment and healing review 29 incomplete , informed consent review 17 incomplete, practical documentation review 36 incomplete, things that cause claim of compensation review complete. The conclusion of calculating result, there are still a lot medical record documents have incompleteness of their fulfillment. As suggestion, management and medical record unit refinement are needed, in order to make medical personnel write data recording completely and continuously. Keyword : Qualitative analysis, Medical record document of patient with diabetes melitus type II disease

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