Analisis Kualitatif Medis Dokumen Rekam Medis Rawat Inap Kasus Typhoid (A01.0) di Puskesmas Sumber Wringin Periode Januari-Juni Tahun 2018 Ratih Wulandari

Wulandari, Ratih (2019) Analisis Kualitatif Medis Dokumen Rekam Medis Rawat Inap Kasus Typhoid (A01.0) di Puskesmas Sumber Wringin Periode Januari-Juni Tahun 2018 Ratih Wulandari. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Background: Medical qualitative analysis is analyzing the completeness of data or information in order to realize quality medical services. Sumber Wringin Health Center has never conducted a qualitative medical analysis of inpatient medical record documents of typhoid cases and still found a lack of completeness and utilization of medical information on typhoid medical record documents. Objective: To analyze qualitative medical records in medical records of inpatient typhoid cases at Sumber Wringin Health Center for the period January-June 2018. Type of research: Qualitative research with observation and interview data collection techniques. Results: History information on medical record documents shows all complete information except for information on extra fever. The physical examination results were found to be 71% high, no 100% dirty tongue, epigastric region 41%. Information on control and monitoring of vital signs is carried out by blood pressure of 90%, temperature of 100%, pulse of 100%, no information on 100% awareness examination. The results of blood pressure, temperature, and pulse of the patient are not stable. Extra blood information complete and widal 90%. Therapy information: resting bed rest and arranging the mobilization stage of 10%, soft TKTP diet 62%, taking medication regularly and completing 100%. The patient's condition returned: the patient's condition recovered 52%, the general condition included both 5%, enough 24%, weak 5%. Normal vital signs (blood pressure, temperature, pulse) 95%, awareness improved 33%, complications 38%, complications resolved 33%, TKTP diet 95%, education rested 48%, administration of drugs when the patient returned 95%. Conclusion: Completeness of medical information on typhoid medical record documents in Sumber Wringin Health Center is still not done optimally. Suggestion: Nurses, doctors, and nutritionists work together to check the completeness of medical records on medical record documents.

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