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

Sari, Dita Nofita (2021) Analisis Faktor Penyebab Ketidaklengkapan Pengisian Berkas Rekam Medis Rawat Inap Di Rumah Sakit : Literature Review. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

According to the Decree of the Minister of Health No. 129 of 2008 concerning Minimum Service Standards for Hospitals requires filling out a 100% complete medical record within 24 hours after completion of service. Research conducted by Nugraheni & Ruslinawati (2013) states that the sample to be carried out is 176 documents, which are completely filled out 0 (0.0%) while those that are not filled out are 176 (100.00%). Medical records that are incompletely filled in can affect the quality of hospital services. In addition, it can affect the services that will be provided to patients if the medical record is not filled out completely. This study aims to analyze the factors causing the incomplete filling of inpatient medical record files at the hospital. The research method used is a literature review of 14 articles that meet the inclusion criteria. The results of this study obtained that the factors that caused the incomplete filling of inpatient medical record files at the hospital with the largest percentage were indiscipline and lack of awareness with a percentage of 79% of the 14 articles reviewed. Suggestions from researchers are conducting seminars and training, providing recapitulation data on incomplete filling of medical record files and carrying out routine reporting related to incomplete filling of medical record files, adding the number of doctors, nurses, other medical personnel, medical record officers and providing a special budget for filling completeness. medical records. Designing an integrated medical record form, involving doctors in providing input regarding the problem of incomplete filling of medical record files. Placing officers according to their educational qualifications. Increase the cooperation of doctors, nurses, medical record officers and other medical personnel in the completeness of filling out medical record files. Provide the facilities needed by doctors to support the completeness of filling out medical record files Key words: incomplete, inpatient, medical record

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