Analisis Faktor Penyebab Ketidaklengkapan Pengisian Dokumen Rekam Medis Rawat Inap di Rumah Sakit: Literature Review
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Institusion
Politeknik Negeri Jember
Author
Rochayani, Bangun Arma Tri
Subject
351 - Kesehatan Masyarakat
Datestamp
2022-07-22 07:48:38
Abstract :
Medical record is a file containing records and documents about patient identity, examination, treatment, actions and other services that have been provided to patients. Completeness of filling out medical records 24 hours after service at the hospital is 100%. The number of incomplete medical records was 43% of the 100 medical record files that were taken randomly. The purpose of this study was to determine the factors causing the incomplete filling of inpatient medical record documents at the hospital. The research method used is a literature review. The articles reviewed were 15 articles that met the inclusion and exclusion criteria. The results showed that the doctor's lack of knowledge about medical records was a factor causing incomplete medical records with the largest percentage, namely 47%. It is necessary to have high knowledge of medical records for doctors, so that medical records have good data quality. For this reason, efforts are made to develop human resources through education and training, especially to doctors in terms of the importance of completing medical record documents, as well as increasing socialization about the importance of completing medical records and the benefits of regular and continuous medical records.
Medical record is a file containing records and documents about patient identity, examination, treatment, actions and other services that have been provided to patients. Completeness of filling out medical records 24 hours after service at the hospital is 100%. The number of incomplete medical records was 43% of the 100 medical record files that were taken randomly. The purpose of this study was to determine the factors causing the incomplete filling of inpatient medical record documents at the hospital. The research method used is a literature review. The articles reviewed were 15 articles that met the inclusion and exclusion criteria. The results showed that the doctor's lack of knowledge about medical records was a factor causing incomplete medical records with the largest percentage, namely 47%. It is necessary to have high knowledge of medical records for doctors, so that medical records have good data quality. For this reason, efforts are made to develop human resources through education and training, especially to doctors in terms of the importance of completing medical record documents, as well as increasing socialization about the importance of completing medical records and the benefits of regular and continuous medical records.
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