Incomplete Inpatient Medical Record Documents at Hospital

Alfiansyah, Gamasiano and Mulia, Alvira Nafisah Eky and Wijayanti, Rossalina Adi and Sabran, Sabran (2022) Incomplete Inpatient Medical Record Documents at Hospital. Jurnal Aisyah : Jurnal Ilmu Kesehatan, 7 (4). ISSN 2502-4825

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Abstract

The medical record contains the patient's identity, examination, treatment, actions and other services that have been provided to patients. There were incomplete integrated patient progress notes 61% and incomplete medical resumes 73%. The research intended to analyze the aspects that caused the incompleteness of inpatient medical record documents at the Besuki Hospital. This research used a qualitative method with data collection techniques interviews, observation dan documentation. The subjects in this study were 1 head of medical records and 5 medical record officers. The result showed that the factors causing the incompleteness of inpatient medical record documents from the motivational variable were that there was still no award and punishment for medical record officers. Opportunity variables were the absence of incomplete record cards, medical record officers who have never attended any training at all, SOPs for checking the completeness of medical records missing and having never been socialized. The ability variable was that there were medical record officers who did not have a minimum education of medical recorders, the knowledge of officers is still lacking and there were officers who had work experience of less than 2 years.

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