Penyebab Ketidaklengkapan Pengisian Lembar Catatan Medik Rawat Inap Di Rumah Sakit : Literatur Review

Dewantara, Dwiki Ananta (2021) Penyebab Ketidaklengkapan Pengisian Lembar Catatan Medik Rawat Inap Di Rumah Sakit : Literatur Review. Diploma thesis, Politeknik Negeri Jember.

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Abstract

Incompleteness of filling medical records is very influential on the quality of medical records, because the quality of medical records is a mirror of the good quality of service in hospitals. The previous review discussed about one of the indicators of quality service is the medical record document of patients who have completed treatment submitted to the assembling section within no later than 2x24 hours with the aim of medical record documents being examined completeness of contents of the data from the medical record document. The pupose of the study was to identify the factors cousing incomplete filling of hospital medical note sheets, man factors, method factors, and material factors. The research method used is literature review using artekel published in 2011-2020 on 4 databases (garuda portal, google scholar, sematic scholar and crossref). A total of 20 articles meet the criteria for inclusion and exculision. The results of the study related to the cause of incomplete filling of medical record sheets are man factors, method factors, and material factors. The main cause of the incompleteness of filling medical records in hospitalization is the lack of education to socialization is a major obstacle to the completeness of the file, lack of discipline in filling medical records, sop does not work well because the flow is not in accordance with standards to continuous information officers who cause incomplete filling, lack of reward punishment that can also be a new study and need to be re-examined in efforts to uncover the completeness of the filling, and the less systematic arrangement of drm can make it difficult to fill by officers. Keywords: incompleteness, Logging Medical Record, hospitalization

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