Analisis Faktor Penyebab Ketidaklengkapan Pengisian Berkas Rekam Medis Pasien Rawat Jalan di Puskesmas Prajekan Kabupaten Bondowoso

Umami, Ainul Rifa Kholifatul (2023) Analisis Faktor Penyebab Ketidaklengkapan Pengisian Berkas Rekam Medis Pasien Rawat Jalan di Puskesmas Prajekan Kabupaten Bondowoso. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

The incompleteness of outpatient medical records at the Prajekan Public Health Center from January to March 2022 in the general polyclinic was 76.7%, the maternal and child health polyclinic was 86.7%, and the dental polyclinic was 86.7%. The incomplete medical records have impact on invalid patient data, incorrect patient identification, incompletely written patient history, and data validity is not legal. This study aims to analyze the factors that cause incomplete filling of outpatient medical records using the 7M Method (Man, Machine, Method, Material, Media, Motivation, Mone) and determine the priority of problems using USG (Urgency, Seriousness, Growth). This type of research uses qualitative research with data collection techniques, namely interviews, observation, and documentation. The research subjects were 1 general poly doctor, 1 dental poly doctor, 1 coordinator midwife, 1 medical records officer, 3 outpatient nurses and 1 head of the public health center. The results showed that the incompleteness of filling out outpatient medical records was caused by doctors and medical record officers who had never attended special training on filling out medical records (man), not using the available checklist sheets in completing medical records (machine), and there was no SOP for filling out medical records (Method). Therefore, the highest problem prioritization is in the man, machine, and method factors. The solution to these problems is to provide, make SOPs for filling out outpatient medical records, and make and socialize related to the availability of checklist sheets for completing outpatient medical records.

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