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

Widiawati, Vina (2021) Analisis Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Rawat Inap di Rumah Sakit : Literature Review. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

According to the Decree of the Minister Health Number 129 of 2008 concerning the minimum standard of service in hospitals, the filling of medical record documents must be 100%. Based on the literature review, it was found that the incompleteness of inpatient medical records in Indrayanti's research results(2018) was 10.28%, Khoiriah(2017) was 17%, Pamungkas, et al(2015) was 49%, Nurhaidah, et al(2016) was 100%. The impact of incomplete inpatient medical records can be a burden on officers in data management. The purpose of this study was to analyze the factors causing the incomplete filling of inpatient medical records at the hospital. This study used a literature review method with 16 articles selected according to the inclusion criteria. The results showed that the factors causing the incomplete filling of medical records by the Man were received less training, lack of human resources, differences in perception, indiscipline and awareness, and low knowledge. Money is limited funds. Material are unsystematic medical record documents and the absence of incomplete logbooks. Method are work procedures because there not SOPs and the flow of medical record files doesn't match standards and the lack of monitoring and evaluation. Machine is the lack of supporting facilities and infrastructure. Motivation is the absence of reward and punishment. Suggestions from this research are providing training, adding human resources, redesigning forms, making incomplete recording books, making SOPs, making medical record documents flows, Forming a team and holding monitoring and evaluation, there are adequate facilities and infrastructure, implementing a reward and punishment.

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