Ferdianto, Angga (2016) Analisis Kualitatif Dokumen Rekam Medis Rawat Inap Pada Pasien Typhoid di Rumah Sakit Daerah dr. Soebandi Jember Tahun 2015. Undergraduate thesis, Politeknik Negeri Jember.
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Abstract
Qualitative analysis of medical record documents are indispensable for the creation of the content of health records which are protected from inputs that are not erect/consistent as well as violation of the recordings that have an impact on the inaccurate and incomplete results. Incorrect/ inappropriate primary diagnosis writing cause difference in BPJS claims rates. The purpose of this study was to analyze qualitative document medical records of hospitalization in patients with Typhoid in RSD dr. Soebandi Jember Year 2015. The type of this research was qualitative research. Data acquisition of this research were observation and open interviews. Results obtained from medical record document observation in RSD dr. Soebandi Jember, incomplete filling of informed consent are as many as 34 files. Assessing the recording as much as 6 files on aspects of writing unreadable no writing illegible physician. History The patient shows symptoms of Typhoid and accompanying symptoms was consistent with the theory. Investigations showed 34 files are not appropriate. Nursing care has been done at the discretion of the hospital, as well as the patient's condition return mostly cured or no improvement. Therefore it is necessary to implement activities that can increase the accuracy / appropriateness of charging medical record them, to punish or reprimand against a doctor or nurse who made a mistake in filling out medical records
| Item Type: | Thesis (Undergraduate) | ||||||
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| Subjects: | 340 - Rumpun Ilmu Kesehatan > 350 - Ilmu Kesehatan Umum > Sistem Informasi Kesehatan | ||||||
| Divisions: | Jurusan Kesehatan > Prodi D4 Manajemen Informasi Kesehatan > Tugas Akhir | ||||||
| Depositing User: | Sri Supriyatiningsih | ||||||
| Date Deposited: | 30 Dec 2025 02:52 | ||||||
| Last Modified: | 30 Dec 2025 02:53 | ||||||
| URI: | https://sipora.polije.ac.id/id/eprint/48898 |
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