Analisis Faktor Penyebab Ketidaklengkapan Pengisian Lembar Resume Medis Di Rumah Sakit: Literatur Review

Shoeleha, Bilqis Almar’atus (2022) Analisis Faktor Penyebab Ketidaklengkapan Pengisian Lembar Resume Medis Di Rumah Sakit: Literatur Review. Diploma thesis, Politeknik Negeri Jember.

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Abstract

Hospitals are required to provide quality health. Thus, hospitals need to improve quality and efficiency supported by various related factors, including medical records implementation. One of the implementations of medical records is a complete medical record. The fact is still many medical record parts that filled incomplete, such as a medical resume form. The research aims to determine the factors causing the medical resume form's incompleteness in the inpatient medical record file. The method used in this study was a systematic review. The results showed that several factors caused the incompleteness of the medical resume form, namely man, methods,materials, machine, and money. Overall, the factors were the busyness of the doctor, disciplineless and knowledgeless of the officers (doctors and nurses), the lack of communication and cooperation between medical record officers and other medical personnel, insufficient numbers and competences of medical records personnel, the absence of SOP related to the completeness of medical resume filling, unimplemented available SOP, unavailability assembling room, insufficient of doctor's name stamp ink, the medical record flows unfitting the SOP, and improperly the activities of monitoring, evaluation and medical resume analysis. Hospitals must pay attention to these factors to maintain the quality of service and medical records. Keywords: Hospitals, Incompleteness, Medical Resume Forms

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