Faktor Penyebab Ketidaklengkapan Pengisian Berkas Rekam Medis Pasien Rawat Inap Di Rumah Sakit: Literature Review

Putri, Angga Kristiana (2022) Faktor Penyebab Ketidaklengkapan Pengisian Berkas Rekam Medis Pasien Rawat Inap Di Rumah Sakit: Literature Review. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

The percentage of complete inpatient medical records at Ganesha Hospital in Gianyar City in 2019 was 81% and at Dharma Kerti Tabanan Hospital in 2019 was 85.78%. Incomplete medical records have an impact on the low quality of medical records and health services. The purpose of this study was to analyze the factors causing the incomplete filling of medical record files for inpatients at the hospital based on the elements of 5M management (Man, Money, Methods, Machine, and Material). This study used the literature review method and found 16 journals and 4 theses from Google Scholar, Crossref, Garuda, and the Jember State Polytechnic E-Library. The inclusion criteria for selecting journals or theses in this study were that the results measured were the factors causing the incompleteness of inpatient medical record files in hospitals, published in 2016–2020, qualitative and qualitative research designs, and not duplicating. The results of the analysis showed that the average percentage of incomplete medical record files was 34.3%. Many items that are not completely filled in from the medical record form include the authentication from doctors and nurses, as many as 7 articles. Factors causing incomplete filling of inpatient medical record files with the highest percentage are the lack of knowledge of officers (40%), lack of budget (15%), the absence of rewards and punishments (50%), the checklist sheet for assessing the completeness of medical record files is not specific or incomplete (15%), and less systematic medical record files (25%). It is necessary to increase the knowledge of officers about the importance of completeness of medical record files, apply a reward and punishment system to motivate officers, and improve checklist sheets and medical record files according to standards.

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