Analisis Faktor Penyebab Ketidaklengkapan Rekam Medis Rawat Jalan di Puskesmas Kasiyan Jember

Savitri, Wardah Arum (2024) Analisis Faktor Penyebab Ketidaklengkapan Rekam Medis Rawat Jalan di Puskesmas Kasiyan Jember. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Medical record is a document containing records of a patient's health services which must be filled in completely within ≤24 hours after service provided. The results of preliminary study at the Kasiyan Jember Primary Health Center found incomplete outpatient medical records with 43% percentage. This study aimed to analyze the factors causing incomplete outpatient medical records at the Kasiyan Jember Primary Health Center. Type of this research is qualitative. The research subjects were 8 informants consisting of 1 head of the primary health center and as dentist, 1 doctor, 1 nurse, 1 midwife, 1 registration and medical records coordinator, and 3 registration and medical records officers. Data collection techniques use are in-depth interviews, observation, and documentation. The results of the research show that causes of incomplete medical records are based on ability factors, namely education of medical record officers is not up to standard, officers have never attended training, and lack of knowledge of officers, motivating factors namely absence of routine evaluation and monitoring of the completeness medical records, opportunity factors, namely incomplete SOP, also no job description for medical records officers. Suggestions in this research are providing training, doing routine monitoring and evaluation, creating and improving SOP of medical records filling and analyzing.

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