Analisis Faktor Penyebab Ketidaklengkapan Pengisian Dokumen Rekam Medis Rawat Inap Di Rumah Sakit: Literature Review

Tirtana, Kevin Zinedine (2021) Analisis Faktor Penyebab Ketidaklengkapan Pengisian Dokumen Rekam Medis Rawat Inap Di Rumah Sakit: Literature Review. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

The completeness of medical record documents is one that affects the quality of medical record services and has an impact on the continuity of the hospital. However, several studies show the completeness of inpatient medical record documents with a percentage of completeness <100%. This has the effect of hampering the processing of medical record data. The purpose of this study is to identify the factors that cause incomplete filling of inpatient medical record documents in hospitals based on the elements consisting of 5M, namely Man, Money, Material, Method and Machine. A total of 20 articles met the inclusion and exclusion criteria. The results showed that the man factor was 45% of the literature caused by the knowledge factor, 30 discipline, 40% caused by the lack of training, 30% of the literature caused by the education factor, 25% of the literature caused by motivation, the method factor 80% of the literature caused by the standard Operational procedures are not optimal, in the material factor 70% of the literature is caused by the medical record document form factor, the machine factor is caused by the facilities and infrastructure factor as much as 65%, the money factor 55% literature is caused by the budget factor. Efforts that can be made to overcome this include increasing the knowledge, motivation and awareness of caregivers about medical records. Organizing training and seminars to make officers understand more about the importance of completing medical resumes considering that not all officers have medical record backgrounds, Socialization of Standard Operating Procedures (SOPs) for complete inpatient medical record documents on a regular basis because knowledge and information on guidance for quality services develop along with is indispensable.

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