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

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

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Abstract

Based on the Health Minister (2008) it is demonstrated that the completeness of medical record documents is 100%. However, in several hospitals, it is still often found that there are incomplete of medical recrods fillings. Iman's research (2011) states that the percentage of incompleteness medical records is 74.8%, in the research of Artini et al. (2017) by 93%, and in the research of Prihandini et al. (2020) of 63.89%. The large number of incomplete medical records can affect and delay in some aspects, for instance delay in concern of patient rights, in the process of classification and codification of diseases, and in hospital reports. The aim of this research is analysing the causing factor of incomplete medical record documents for inpatients in hospital. The researcher utilized 5M elements of management, such as Man, Materials, Method, Machine, dan Money. This study was conducted using the design literature review approach and concerned 14 articles, in detail 14 journals that selected precisely though Google Scholar, Garuda, and Crossref. The findings of this study can be displayed from analysing 14 articles, the causing factor of incomplete medical record documents for inpatients in hospitals is lack of doctors’ discipline in completing medical records, lack of socialization regarding filling out medical documents, the facilities and infrastructure to support medical record filling activities are still inadequate. Furthermore, there are no rewards and punishments, limited funds to support activities and facilities and infrastructure for filling out medical records. The suggestions offered by the researcher are conducting training and seminars on medical records and filling out medical record files, creating the new regulation regarding rewards for officers who complete the medical record documents with punishment for officers who don’t fill out medical records, conducting socialization of medical records, planning the budget for activities as well as completing facilities and supporting infrastructure for filling out medical records.

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