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

Kartika, Bhilqis Nabila Rahma (2022) Analisis Faktor Penyebab Ketidaklengkapan Pengisian Dokumen Rekam Medis Rawat Inap di Rumah Sakit: Literature Review. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Filling medical records still often occurs incompleteness in charging. Incomplete medical records can lead to hampered quantitative analysis for data information processing. Another impact that can be caused is the quality of medical records will decrease because KLPCM is not 100%. This type of medical record service has an indicator of completeness of filling medical records 24 hours after service delivery must reach the 100% standard. The purpose of the study was to analyze the factors causing the incomplete filling of medical record documents in hospitals. The method in this study uses literature review through reading by searching various sources of articles including Google Scholar, Crossref and Garuda Portal. Articles that have been reviewed as many as 17 articles that have met the criteria of inclusion in accordance with the research topic. The results stated that the causative factors of the incompetence of filling from the Man factor with the most influencing factors are work discipline. Machine factor with the most influencing factors is the constraints on the tools used to facilitate work. Method factor with the most influencing factor is the absence of socialization of the procedure. Material factors with the most influencing factors are inefficient documents. Money factor with the most influencing factors is funds or budgets to achieve organizational goals. So that the advice that can be given by the author by providing training to officers, procurement monitoring and evaluation, procurement of SOP filling out medical record forms accompanied by socialization, evaluating the format of forms and filing operational funds.

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