Analysis of Filling in the Inpatient Medical Record Files at Arjasa Health Center Jember

Wijayanti, Rossalina Adi and Surur, Hikmatus and Nuraini, Novita and Muflihatin, Indah (2021) Analysis of Filling in the Inpatient Medical Record Files at Arjasa Health Center Jember. Jurnal Aisyah: Jurnal Ilmu Kesehatan, 6 (2). pp. 273-278. ISSN 2502-9495

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Abstract

The Medical record form is an important means of communication because it records detailed data about all actions taken by medical officers. The activities of filling in medical records in Arjasa Health Center are applied less sufficiently. This can be seen from some incomplete filling of the medical record. It impacts the process of classification, and diseases coding, reporting, and claims submission. This study aims to analyze the filling of medical records files in the Arjasa Health Center, Jember Regency. This type of research is qualitative research. The data collections are interviews, observations, documentation, and questionnaires. There 5 subjects of the study which consist of medical record officer, nurse, midwife, nutrition officer, and doctor. The results show several factors that cause incomplete filling of the medical records are the absence of medical record training for officers, SOP, qualified officer, punishment and reward for officers’ performance. The efforts to solve these problems obtained by brainstorming include conducting medical record training, recruiting officers based on the qualifications, creating and socializing SOP, providing punishment or reward to officers with good performance in filling in the files completely and appropriately.

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