Analisis Kuantitatif Dan Kualitatif Rekam Medis Kasus Carcinoma Mammae Di Rumah Sakit Baladhika Husada

Wiyanto, Bagas Rahmanda (2023) Analisis Kuantitatif Dan Kualitatif Rekam Medis Kasus Carcinoma Mammae Di Rumah Sakit Baladhika Husada. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Baladhika Husada Hospital in January 2023. The problem encountered is the still high rate of incompleteness and inconsistency of medical records of the DMR type in the first quarter of 2023. The purpose of this study was to analyze quantitative and qualitative medical records mammae carcinoma case at Baladhika Husada Hospital using Hatta's theory. This type of research is a mix method with data collection techniques using observation, interviews, and documentation. The population in this study were 664 mammae carcinoma medical records, with a total sample of 85 medical records. The results of this study are that the highest incompleteness in the quantitative analysis is found in the fixed line criteria, which is equal to 98.82%; in the administrative qualitative analysis, the highest incompleteness was found in the informed consent criteria, namely 88.24%; and in the medical qualitative analysis, the highest incompleteness was found in the staging criteria, namely 100% of medical records did not contain "extra" information and information related to the patient's stage. The conclusion of this study is that incompleteness and inconsistency in medical record filling are still found. Based on this description, the hospital should redesign the form and add to the medical record form for cancer patients; the hospital needs to socialize the use of ink, procedures for correction, and the use of abbreviations; doctors should be more careful in enforcing and writing a diagnosis and writing down the stage in the medical record; health workers should have a name stamp for signing; The Medical Record Unit should do the reassembling of each medical record; health workers and students who use medical records should always keep the forms so that they are not scattered.

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