Analisis Faktor Penyebab Ketidaklengkapan Pengisian Resume Medis Rawat Inap di RSU dr. H. Koesnadi Bondowoso

Dewi, Ida Ayu Kurnia (2023) Analisis Faktor Penyebab Ketidaklengkapan Pengisian Resume Medis Rawat Inap di RSU dr. H. Koesnadi Bondowoso. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Amount incompleteness in inpatient medical resumes filling in the first quarter and second quarter of 2022 was 33% with a total sample was 194 files. This study aimed to analyze the causal factors contributing to the incompleteness of inpatient medical resumes at dr. H. Koesnadi Bondowoso Regional Hospital used Lawrence Green's behavioral theory, comprised of predisposing, enabling, and reinforcing factors. The type of research used was qualitative, employing data collection techniques such as interviews, observations, and documentation. The tool for determining problem priorities and improvement efforts used USG and brainstorming. The research subjects included the head of medical records, three doctors, three nurses, three administrators, and one medical records assembling officer. Based on the problem priorities determined using USG, the research findings identified the causes of the problem. These included the lack of discipline among physicians in filling out medical resumes, insufficient knowledge among staff regarding completeness, the presence of doctors with dual job descriptions, the absence of Standard Operating Procedures (SOPs) for completing medical resumes, and still many officers who do not followed the socialization of medical record SOPs. The improvement efforts identified included conducting socialization regarding filling out forms, establishing collaboration between nurses and administrators to remind physicians, having physicians promptly fill out medical record resumes after outpatient visits, providing training on completeness filling, limiting physician's working hours and the number of patients they handled, creating SOP for medical resume completeness, and conducting a re-socialization regarding SOP. This research concluded the causal factors of the problem were founded in the predisposing factors and reinforcing factors.

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