Analisis Faktor Penyebab Perilaku Ketidaklengkapan Pengisian Berkas Rekam Medis Rawat Inap di Rumah Sakit: Literature Review

Putri, Rini Indriani (2021) Analisis Faktor Penyebab Perilaku Ketidaklengkapan Pengisian Berkas Rekam Medis Rawat Inap di Rumah Sakit: Literature Review. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Every health care facility must hold medical records including hospitals in order to achieve administrative order. Completeness of medical records is one of the efforts to improve the quality of health services. But in fact, the incompleteness of medical records files is still found in some hospitals. This study aims to determine the behavioral factors of incomplete filling in the inpatient medical records file. This research method is literature review using articles published in Google Scholar database, Portal Garuda, and E-Library Polije with a minimum issue of the last 10 years (2010-2020). Article search results obtained 44 articles, then reselected using inclusion criteria resulting in 20 articles. The results showed that there are several factors that cause incomplete filling of medical records as seen from the predisposing factors, including the knowledge and attitude of officers towards the filling of medical records files (90%), enabling factors including the availability of facilities and infrastructure (30%), reinforcing factors including monitoring and evaluation of the implementation of completeness of medical record file (35%); Standard Operating Procedure (SOP) (80%); and the implementation of reward and punishment system (45%). Such incompleteness will have an impact on the resulting information to be unsustainable thus affecting patient safety. Efforts that can be made to overcome it are forming a monitoring team and conducting regular evaluations, conducting regular and thorough socialization related to Standard Operational Procedures (SOP), the implementation of reward and punishment systems to increase motivation and awareness and discipline of officers.

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