Analisis Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis di Klinik Wirasakti Jember

Sukma, Harnis Tika (2023) Analisis Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis di Klinik Wirasakti Jember. Diploma thesis, Politeknik Negeri Jember.

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Abstract

The percentage of incomplete medical records in the Wirasakti Jember Clinic has increased, which in June 2022 was 49%. This affects the quality of medical records because they do not contain complete information. The purpose of this research is to analyze the factors that cause the incompleteness of filling out the medical records of road care at the Jember Clinic based on the performance theory of Armstrong and Baron. The type of research used is qualitative, with observational data collection techniques, in-depth interviews, and documentation, The methods used are ultrasound (Urgency, Seriousness, Growth) and discussion. The research subjects consist of 9 informants, consisting of 2 doctors, 2 registration officers, 1 medical record officer, 2 nurses, 1 PJ Medical Record, and the Head of Clinic Wirasakti Jember. The results of this research are Individual Factors, there are officers who have not had the minimum education qualification of DIII RMIK, the whole has not attended seminars or training on medical records, and the lack of knowledge of officers related to the minimum standard of medical records. Leadership factors, motivation in the form of rewards have not been given to all officers and have not engaged all officials in the implementation of the evaluation of the completeness of the completion of medical records. The group factor is that communication between colleagues is not optimal. System factors, the use of a checklist is not optimal, there is no SOP (Standard Operating Procedure) specific medical record filling, and SOP socialization is inconsistent. There are officers who have a double job. The improvement effort is to delegate officers to follow medical record training, make detailed medical record filling SOP, and conduct SOP socialization consistently. The Clinic is advised to delegate PJ RM to attend the seminar, involving representatives of each unit to carry out an evaluation of completeness and the addition of medical recorders. Keywords: Clinic, Incompleteness, Medical recordS

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