Analisis Kualitatif Berkas Rekam Medis Rawat Inap Pada Pasien Penyakit Jantung Iskemik Di RSD. dr. Soebandi Jember Tahun 2014

Apriyanti, Windari Eka (2016) Analisis Kualitatif Berkas Rekam Medis Rawat Inap Pada Pasien Penyakit Jantung Iskemik Di RSD. dr. Soebandi Jember Tahun 2014. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Incomplete filling medical record file will make it difficult for health workers take action or treatment before knowing the history of the disease, action or therapy ever given to patients who are in the medical record file, so that the data contained in the medical record file can be said is inaccurate. Based on the preliminary survey done about the completeness of medical record file of hospitalizations for ischemic heart disease in RSD dr. Soebandi Jember 50 files taken at random, 40% of the file is not filled in completely, so the researchers aim to determine the quality of medical record file of hospitalization in patients with ischemic heart disease in RSD dr. Soebandi Jember 2014 by identifying the completeness of the medical record file. This type of research is descriptive qualitative study population of 109 medical record file and samples used were 86 medical record file. From the results, medical record file of hospitalization in patients with ischemic heart disease have a poorer quality based identification completeness of files and has a good quality when the review is based on the suitability of medical action with PROTAP heart disease and blood vessels that are used in the RSD dr. Soebandi Jember. Therefore, it is necessary to label printing tool for identifying patient to assist officers in writing idnetitas patients on medical record file, hold a sheet re-socialization related functions incompleteness of medical records and their reward as well as punishment for doctors and nurses.

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