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

Agustina, Elda Amalia (2021) Faktor Penyebab Ketidaklengkapan Pengisian Dokumen Rekam Medis Rawat Inap di Rumah Sakit: Literature Review. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Several hospitals in Indonesia were found to have not filled out complete medical record documents. The existence of such incompleteness causes the records contained to be out of sync and would be difficult to identify. The purpose of this study was to analyze the factors causing the incompleteness in filling the documents of the patients' medical record at the hospital. The method used in this research was Literature Review. This research was conducted by searching on online databases, namely Google Scholar, Perpusnas, and Garuda Portal from 2011 up to 2021. The keywords entered were the incompleteness in filling the documents of the patients' medical record at the hospital, and 106 articles were found. Those 106 articles would be selected according to the inclusion criteria and exclusion criteria. It was found that the titles identified were 56 articles, the abstracts identified were 25 articles, so the number of articles that need to be reviewed were 25 articles. The results of the analysis of 25 articles found that the factors causing the incomplete in filling the documents of the patients' medical record at the hospital were the absence of Standard Operating Procedures regarding the completeness of medical record documents or the implementation of Standard Operating Procedures that had not been maximized by 44%, lack of discipline of medical officers, monitoring and evaluation had not been carried out each as much as 24%, lack of awareness of medical officers in filling out complete medical record documents as much as 20%, lack of accuracy of medical officers, lack of socialization, limited time, and busy doctors respectively 16%. Hospitals are needed to pay attention to the factors causing the incompleteness so that they can provide good quality of services for the patients.

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