Analisis Penyebab Ketidaklengkapan Rekam Medis di UPTD Puskesmas Wonoasih Kota Probolinggo

Oktaviani, Catelina Friska Diah (2022) Analisis Penyebab Ketidaklengkapan Rekam Medis di UPTD Puskesmas Wonoasih Kota Probolinggo. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

A medical record is a document that contains records of services provided to patients that must be filled in completely in the identification section, important reports, authentication, and recording techniques filled out by both doctors and medical record officers. Based on the results of the preliminary study, researchers obtained information on the incompleteness of medical records at the UPTD Puskesmas Wonoasih, Probolinggo City from September to November 2021, namely the total number of medical records as many as 2308 files with an average number of medical records filled in completely as many as 684 files (88.96%) while those that were not completely filled were 85 files (11.14%). The purpose of this study was to analyze the causes of incomplete medical records at the UPTD Puskesmas Wonoasih, Probolinggo City. This type of research uses qualitative research, the research subjects are in the form of 1 head of puskesmas, 4 doctors, and 2 medical record officers, with the object of the study being a clinical preliminary assessment form and an outpatient medical record form. The results of the study explained that the cause of the incompleteness of medical records at the UPTD Puskesmas Wonoasih, Probolinggo City, was caused by the absence of rewards for officers and the socialization of SOPs was not optimal. So, the advice that can be done is that medical record officers can record every month based on the name of the doctor who fills in completely or not, then can be given a compliment and socialize SOPs regularly. Key words: cause, incompleteness, individual behavior, medical record

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