Analisis Faktor Penyebab Ketidaklengkapan Pengisian Dokumen Rekam Medis Pasien : Literature Review

Zatin, Widian Almas (2021) Analisis Faktor Penyebab Ketidaklengkapan Pengisian Dokumen Rekam Medis Pasien : Literature Review. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

A good and quality medical record services can be seen from the contents of the completeness of the file, timely, accurate and fulfillment in terms of legal requirements. The ideal standard for the completeness of medical record documents is 100%. However, based on a literature review, 100% of incomplete medical record documents were found, in the results of the research by Lestari & Muflihatin (2020) by 53.08% of 1404 DRM, Karmila (2019) by 74% of 50 DRM, Gosanti & Ernawaty (2018) by 53.1% of 500 DRM, Wimala (2018) by 33% of 58 DRM, and Rudi (2020) by 60 % of 30 DRM. The incident of filling incompleteness of medical record documents can affect many things, including delays in fulfilling the patient's rights to the contents of medical records, and most importantly can affect the quality of medical record services. This study aims to analyze the filling incompleteness causing factors of medical record documents at public health center. The research method used was a literature review of 12 articles that matched the inclusion criteria. The results of this study obtained that the biggest factor was the individual variable, namely the skill factor by 75%, then the knowledge factor was 50%, and the lowest percentage was the ability factor by 16.67%. On the organizational variable, namely the leadership factor by 50%. The motivator variable is the motivator factor by 16.67%. Suggestions from this study are the necessity to provide training and seminars to officers, create and socialize SOPs as guidelines and references for officers in documenting medical record documents, leaders provide forms of control and evaluation, further researchers are expected to conduct similar research with the same model or more developed method such as making comparisons with other health institutions or health centers so that it will further enrich the research results.

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