Analisis Faktor Ketidaklengkapan Pengisian Berkas Rekam Medis Rawat Inap di Rumah Sakit : Literatur Review

Agustina, Nawang Bekti (2021) Analisis Faktor Ketidaklengkapan Pengisian Berkas Rekam Medis Rawat Inap di Rumah Sakit : Literatur Review. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Hospitals are required to provide quality health services. This encourages efforts to improve the quality and efficiency of services in hospitals with the support of various related factors, one of which is the administration of medical records. One of the medical records is a complete medical record. In fact, there are still many medical records that have not been filled out completely. This study aims to determine the factors causing the incomplete filling of inpatient medical records in hospitals by using the literature review research method. The results showed that there were several factors causing the incomplete filling of inpatient medical records in terms of human resources, methods, materials, tools, and finances. Overall, the contributing factors are the busyness of doctors, lack of discipline of officers (doctors and nurses), lack of knowledge of officers, lack of communication and cooperation between medical record officers and other health workers, insufficient medical record personnel both in terms of number and in terms of the competence of medical recorders, the absence of SOPs related to the completeness of filling out medical records, available SOPs but not running well, the flow of medical record files is not in accordance with standard procedures for administering medical records, monitoring and evaluation systems and medical record file analysis activities have not gone well. Hospitals need to pay attention to these factors so that they can maintain the quality of service and the quality of hospital medical records.

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