Analisis Kuantitatif Dan Kualitatif Rekam Medis Rawat Jalan Pasien Tuberkulosis Paru Di Puskesmas Mayang Jember

Sudianta, Bella (2025) Analisis Kuantitatif Dan Kualitatif Rekam Medis Rawat Jalan Pasien Tuberkulosis Paru Di Puskesmas Mayang Jember. Undergraduate thesis, Polteknik Negeri Jember.

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Abstract

Pulmonary tuberculosis is the first diagnosis in the top 10 outpatient visits at the Mayang Health Center in 2024. The problem encountered was the high rate of incomplete and inconsistent medical records. The purpose of this study was to analyze quantitative and qualitative medical records pulmonary tuberculosis patient at Mayang Health Center using Hatta's theory. This type of research is a descriptive quantitative with data collection techniques using observation and documentation. The population in this study were 191 pulmonary tuberculosis medical records, with a sample of 128 medical records. The results of this study show that quantitative analysis revealed 100% data incompleteness in the Outpatient Reassessment Form under the criteria of record validity and timing. Qualitative administrative analysis revealed 100% inconsistency in the criteria of incomplete filling, meanwhile, the medical qualitative analysis showed that medical records were of poor quality at 100% in the criteria of chest pain, night sweats, TTV examination, weight measurement, and dosage administration. The conclusion of this study is that there was incompleteness in the quantitative analysis, inconsistency in the administrative qualitative analysis, and poor-quality medical records in the medical qualitative analysis. Based on the above, the Mayang Health Center should design the RME format in accordance with quantitative and qualitative analysis guidelines, establish guidelines for the use of codes and symbols, and conduct outreach related to quantitative and qualitative analysis. Additionally, tuberculosis clinic staff should always ask patients about their complaints according to standards, conduct complete TTV examinations, and weigh patients' body weight at each visit, then record all results in the medical record. If manual medical records are still used, it is recommended to provide identity stickers, name stamps, and always include the signature and full name of the healthcare provider.

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