Analisis Kuantitatif Rekam Medis Unit Rawat Inap Penyakit Typhoid Fever (A01.0) di Rumah Sakit IHC Jatiroto Tahun 2025

Prasetyo, Andre Eka (2026) Analisis Kuantitatif Rekam Medis Unit Rawat Inap Penyakit Typhoid Fever (A01.0) di Rumah Sakit IHC Jatiroto Tahun 2025. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Typhoid Fever was the leading diagnosis among the top ten inpatient diseases during the first quarter of 2025 at RS IHC Jatiroto. The problem identified was the incomplete documentation of inpatient medical records for Typhoid Fever cases. Incomplete medical record documentation could affect the quality of healthcare services, the effectiveness of communication among healthcare professionals, as well as the hospital's reporting and evaluation processes. This study aimed to conduct a quantitative analysis of medical records. This research employed a descriptive research method. Data were collected through observation, unstructured interviews, and documentation. The study population consisted of 356 inpatient medical records of Typhoid Fever cases from the first quarter of 2025, with a sample of 76 medical records determined using stratified random sampling. The research instrument was a checklist consisting of the variables of social data, recording evidence, record validity, and documentation procedures. The results showed that the completeness of medical record documentation had not yet achieved the 100% standard. Incomplete documentation was still found in the aspects of social data and record validity. The average completeness of the social data aspect was 90%, with patient age and informed consent signatures being the most frequently incomplete items. The average completeness of the record validity aspect was 72%, primarily because the signatures of healthcare professionals providing services were still incomplete on several medical record forms. Therefore, improving healthcare professionals' compliance with medical record documentation, conducting regular evaluations, and strengthening quantitative medical record analysis activities in accordance with established standards are necessary to enhance the quality of healthcare services in hospitals. And integrated the existing age aspect in the patient demographic tabulation in SIMRS into all patient medical record forms

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