Analisis Faktor Penyebab Ketidaklengkapan Pengisian Formulir Laporan Operasi di Rumah Sakit Umum Kaliwates Jember

Avisa, Felda Risqi (2026) Analisis Faktor Penyebab Ketidaklengkapan Pengisian Formulir Laporan Operasi di Rumah Sakit Umum Kaliwates Jember. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Incomplete completion of operative report forms remains a problem at Kaliwates General Hospital, Jember. Data from April–September 2024 showed a completeness rate of 51% and an incompleteness rate of 49%, failing to meet the minimum service standard of 100% within ≤24 hours, with the highest incompleteness found in the duration of surgery section. Data from 2022–2024 also indicate an increasing trend in incomplete operative reports. This condition may affect service quality, legal aspects, and the continuity of patient medical information. This study aimed to analyze the factors causing incomplete completion of operative report forms in terms of personal, leadership, system, team, and contextual factors. This research employed a qualitative design involving 12 informants consisting of 7 nurses, 4 specialist doctors, and 1 head of the medical records unit. Data collection techniques included in-depth interviews, observation, documentation, the USG (Urgency, Seriousness, Growth) method, and discussions. The results showed that personal factors included the absence of specific training on proper form completion. Leadership factors involved the lack of strict sanctions and the absence of reward systems. System factors were related to the irregular and uneven dissemination of SOPs. Team factors included difficulty contacting doctors, tight schedules, shift changes, and limited time for completion, resulting in suboptimal cross-checking. Contextual factors involved significant work pressure. Recommended solutions include periodic training, written sanction policies and reward systems, routine SOP dissemination, strengthened communication and completion deadlines, workload evaluation, and implementation of Electronic Medical Records with mandatory field features to minimize incompleteness.

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