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

Pratiwi, Dita Melinda (2022) Analisis Faktor Penyebab Ketidaklengkapan Pengisian Dokumen Rekam Medis Rawat Inap Di Rumah Sakit: Literature Review. Diploma thesis, Politeknik Negeri Jember.

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Abstract

Hospitals are required to provide quality health services. This encourages efforts to improve the quality and efficiency of services in hospitals with the support of various related factors, one of which is the administration of medical records. One of the medical records is a complete medical record. In fact, there are still many medical records that have not been filled out completely so that they are not in accordance with the Regulation of the Minister of Health of the Republic of Indonesia Number 129 of 2008 concerning Minimum Service Standards in Hospitals stating that the completeness of medical record documents is 100%. This study aims to determine the factors causing the incomplete filling of inpatient medical record documents. The method used in this study is a literature review with 15 journals that have been selected according to the inclusion criteria. The results showed that there were several factors causing incomplete filling of inpatient medical record documents seen from the man factor, namely the lack of knowledge of officers, indiscipline of officers, lack of motivation of officers, high workload, and no training. The machine factor is the lack of communication between officers, the absence of monitoring and evaluation of medical records, and the absence of sanctions or awards. The method factor is that the implementation of filling out inpatient medical record documents is not in accordance with the SOP (Standard Operating Procedure). Material factors, namely medical record documents need to be simplified, there is no special room to fill out medical records, and there is no incomplete recapitulation data and the money factor is a limited budget. Hospitals need to pay attention to these factors so that they can maintain the quality of service and the quality of hospital medical records. Keywords: Incompleteness, medical record documents, inpatient unit

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