Analisis Ketidaklengkapan Resume Medis Kasus Pneumonia Pasien Rawat Inap Di Rumah Sakit Wijaya Kusuma Lumajang Dengan Metode Fishbone Tahun 2015

Prianti, Apriliani (2016) Analisis Ketidaklengkapan Resume Medis Kasus Pneumonia Pasien Rawat Inap Di Rumah Sakit Wijaya Kusuma Lumajang Dengan Metode Fishbone Tahun 2015. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Resume is a medical form that must be preserved. This sheet must be signed by the treating physician. Based on a preliminary survey at the Hospital Wijaya Kusuma Lumajang, filling in the forms Resume Medical in pneumonia patients were 124 medical records found incompleteness document form filling in the address item, diagnosis and terangdokter name. The purpose of this study was to analyze charging Resume Form Inpatient Medical pneumonia in 2015 at the Hospital Wijaya Kusuma Lumajang. This type of research is descriptive, the subjects in this study consisted of four informants ie doctors, nurses, and medical recorder. The samples used were 124 documents medical records of the total population. Way of collecting data through observation, interviews, and documentation. The results obtained by filling out medical resume (unfilled), the largest found on the item name that is 100% (124 form) and form filling Resume Medical (unallocated), the largest found in the item name explained the doctor is (42 forms) and address ie (41 form) , Not being filled item name because at the time the patient mendaftat not match with the ID card. The results of this study can be concluded that the need to increase the rigor and discipline to the competent authorities in charge of administrative data, clinical data and authentication, the need for cooperation between medical records clerk with the other units, especially doctors and nurses in the medical record to complete the form.

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