ANALISIS FAKTOR PENYEBAB KETIDAKLENGKAPAN PENGISIAN DOKUMEN REKAM MEDIS RAWAT INAP DI RUMAH SAKIT: LITERATUR REVIEW

Alfiansyah, Gamasiano and Pratiwi, Dita Melinda and Nuraini, Novita and Nurmawati, Ida (2022) ANALISIS FAKTOR PENYEBAB KETIDAKLENGKAPAN PENGISIAN DOKUMEN REKAM MEDIS RAWAT INAP DI RUMAH SAKIT: LITERATUR REVIEW. Jurnal Penelitian Kesehatan Suara Forikes, 13 (Nov). pp. 288-293. ISSN 2502-7778

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Abstract

One of the characteristics of good medical record management is a complete medical record. This study aims to determine the factors causing the incomplete filling of inpatient medical record documents. The method used in this study was a literature review with 15 journal articles that had been selected according to the inclusion criteria. The results showed that there were several factors causing incomplete filling of inpatient medical record documents as seen from the "man" factor, namely lack of knowledge of officers, indiscipline of officers, lack of motivation of officers, high workload, and no training. The "machine" factor is the lack of communication between officers, the absence of monitoring and evaluation of medical records, and the absence of sanctions or rewards. The "method" factor, namely the implementation of filling out inpatient medical record documents is not in accordance with the SOP (Standard Operating Procedure). The "material" factor, namely medical record documents need to be simplified, there is no special room to fill in medical records, and there is no incomplete recapitulation data and the "money" factor, namely a limited budget. Hospitals need to pay attention to these factors so that they can maintain the quality of service and the quality of hospital medical records.

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