Quantitative analysis of the completeness of medical records documents for inpatient general surgery patients at X Padang Hospital

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Published Oct 30, 2023
https://doi.org/10.35335/midwifery.v11i4.1371
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Vol. 11 No. 4 (2023): October: Midwifery and Health Sciences

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Dewi Oktavia
APIKES IRIS, Indonesia

Abstract

The quality of medical records is an indicator of the quality of hospital services which can be seen from the completeness of filling out medical record documents. Incompleteness in filling out medical record documents will disrupt administrative order which will affect the patient treatment process, where officers will have difficulty identifying the patient, officers will have difficulty determining the next treatment or therapy action that will be carried out on the patient. Based on the results of the initial survey at Hospital X Padang, it was found that a quantitative review of medical record documents had never been carried out. The aim of this study was to determine the results of a quantitative review of the completeness of medical records for general surgery inpatients. This research method is descriptive with a quantitative approach. The population and sample in this study were documents from inpatients specifically for general surgery in the fourth quarter of 2021, with a total sample of 38 documents. The research location is at Hospital the doctor's hand was 94.7%, the method of recording abbreviated items was 73.7%. From the results of the quantitative analysis research, it was concluded that it still does not meet the Minimum Service Standards, namely 100%. To increase the completeness of filling out medical records, it is hoped that hospitals can create reward and punishment policies, implement rules or SOP guidelines for filling out medical record documents.

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How to Cite
Oktavia, D. (2023) “Quantitative analysis of the completeness of medical records documents for inpatient general surgery patients at X Padang Hospital”, Science Midwifery, 11(4), pp. 732-738. doi: 10.35335/midwifery.v11i4.1371.

References

Agustri, D., Rikomah, S. E., & Sari, Y. (2021). PENGKAJIAN KELENGKAPAN RESEP PADA PASIEN RAWAT JALAN TAHUN 2020 DI RSUD BENGKULU TENGAH. Stikes Al-Fatah Bengkulu.
ALLPANDIANTO, S. (2021). TINJAUAN KELENGKAPAN REKAM MEDIS PADA PASIEN TUBERKULOSIS DI RUMAH SAKIT Tk. IV DKT MADIUN. STIKES BHAKTI HUSADA MULIA.
Anggraeni, A., & Herlina, I. (2022). Analisis Kelengkapan Pengisian Dokumen Rekam Medis Rawat Inap di UPT RSUD Cikalong Wetan. Jurnal Bidang Ilmu Kesehatan, 12(1), 48–54.
Bete, M. A., & Nurvita, S. (2023). Analisis Kuantitatif Kelengkapan Pengisian Catatan Perkembangan Pasien Terintegrasi Dokumen Rekam Medis Rawat Jalan Di Rumah Sakit Jiwa Daerah Abepura Periode Februari Tahun 2022. Jurnal Rekam Medis & Manajemen Infomasi Kesehatan, 3(1), 46–59.
Budiyasa, I. W. (2020). Analisis kemampuan mahasiswa progam studi pendidikan biologi fpmipa ikip pgri bali dalam menyusun rencana pelaksanaan pembelajaran (rpp) biologi sma/ma kurikulum 2013 sesuai permendikbud nomor 22 tahun 2016. Widyadari, 21(1).
Citra, B. (2015). Landasan Teori, kerangka Teori, Pengelolaan Rekam Medis. Jakarta: EGC.
Hardani, H., Andriani, H., Ustiawaty, J., & Utami, E. F. (2020). Metode penelitian kualitatif & kuantitatif. Pustaka Ilmu.
Hatta, G. R. (2008). Pedoman Manajemen Informasi Kesehatan di sarana pelayanan kesehatan. Jakarta: Universitas Indonesia.
Huffman, E. K., & Edna, R. R. A. (1994). Health Information Management, Physicians’ Record Company. Beryn, IIIioni, 1(2).
Lily, W., & Deasy, R. D. (2017). Manajemen Informasi Kesehatan II: Sistem dan Subsistem Pelayanan RMIK. Kementerian Kesehatan Republik Indonesia.
Luhukay, R. S. (2021). Pemenuhan Jaminan Kesehatan Oleh Perusahaan Dalam Perpektif Peraturan Pemerintah Nomor 86 Tahun 2013. Jurnal Ilmiah Living Law, 13(2), 111–121.
NABELA, S. R. (2018). PENGARUH BERMAIN TEKA-TEKI TERHADAP KEMAMPUAN MENGENAL KEAKSARAAN PADA ANAK KELOMPOK B DI TK MARDISIWI MATARAM BARU LAMPUNG TIMUR TAHUN AJARAN 2016/2017.
Nisa, S. R. K. (2021). Analisis Kuantitatif Dokumen Rekam Medis Pasien Rawat Jalan di Puskesmas Gondanglegi. Health Care Media, 5(2), 88–95.
Nomor, U.-U. (44 C.E.). tahun 2009 tentang Rumah Sakit.
Nugraha, D. B., & Ningsih, W. (2022). Pengaruh Pengendalian Internal dalam Meningkatan Efektifitas Kinerja Operasional Pengelolaan Sampah. Jurnal Wacana Ekonomi, 21(2), 108–121.
Oktavia, D. (2020). Analisis Ketidaklengkapan Pengisian Lembar Informed Consent Pasien Bedah di Rumah Sakit Tk. III dr. Reksodiwiryo Padang. Jurnal Manajemen Informasi Kesehatan Indonesia, 8(1), 24.
Purwanti, I. S., Prihatiningsih, D., & Devhy, N. L. P. (2020). Studi Deskriptif Kelengkapan Dokumen Rekam Medis. Jurnal Rekam Medis Dan Informasi Kesehatan, 3(1), 36–39.
Rehatta, N. M., Chandra, S., Sari, D., Lestari, M. I., Senapathi, T. G. A., Nurdin, H., Wirabuana, B., Pramodana, B., Pradhana, A. P., & Isngadi, I. (2022). Comorbidities and COVID-19 status influence the survival rate of geriatric patients in intensive care units: a prospective cohort study from the Indonesian Society of Anaesthesiology and Intensive Therapy. BMC Geriatrics, 22(1), 1–9.
RI, D. (2008). Keputusan Menteri Kesehatan Republik Indoneia Nomor. 129 Tahun 2009 Tentang Standar Pelayanan Minimal Rumah Sakit. Jakarta: Kemenkes RI.
Rizkika, M. Y. (2020). Analisis Kuantitatif Kelengkapan Dokumen Rekam Medis Pasien Rawat Inap Dengan Diagnosa Fracture Femur Di RSUD Dr. RM Djoelham Binjai. Jurnal Ilmiah Perekam Dan Informasi Kesehatan Imelda, 5(1), 62–71.
Suaryanti, N. M. A., Wirajaya, M. K. M., & Sudiari, M. (2022). Analisis Kelengkapan Rekam Medis Pasien Rawat Inap Fraktur Tulang Anggota Gerak di Rumah Sakit Bhayangkara Denpasar. Jurnal Kesehatan Vokasional, 7(2), 70–78.
Sumargo, B. (2020). Teknik sampling. Unj press.
Swari, S. J., Alfiansyah, G., Wijayanti, R. A., & Kurniawati, R. D. (2019). Analisis Kelengkapan Pengisian Berkas Rekam Medis Pasien Rawat Inap RSUP Dr. Kariadi Semarang. ARTERI: Jurnal Ilmu Kesehatan, 1(1), 50–56.
Wijaya, A. (2022). Hukum Jaminan Sosial Indonesia. Sinar Grafika.
Yanti, N. K. W., & Yulianti, M. S. (2023). Analisis Kelengkapan Dokumen Rekam Medis Pada Formulir Ringkasan Masuk dan Keluar Kasus Poli Penyakit Dalam Pasien Rawat Inap di Rumah Sakit Umum Daerah Provinsi NTB. Medika: Jurnal Ilmiah Kesehatan, 3(1), 1–6.