Abstract
Hospital is an organization engaged in services, therefore it is obliged to hold a medical record for the achievement of good administration. Registration, data filling, processing and analysis as well as documentation, this is the process of organizing medical records. Filling in the medical record is said to be good if each item on the medical record sheet is filled with complete data. A complete medical record is a quality image of a hospital. Based on the above background, the researcher wants to find out the percentage of completeness of medical record filling in the inpatients of Ganesa hospital in the city of Gianyar. This type of research is a descriptive study with a cross-sectional design. The sample in this study was 95 inpatient medical record files. Percentage of completeness for RM Patient identity is 100%, doctor's identity is 96.8%, nurse's identity is 85.3%, informed consent is 95.8%, anesthesia is 43.2%, resume is 100%, diagnosis is 100%, abbreviations of 66.3%, readability of 76.8%, rectification of 23.2% and structuring of 100%. The incompleteness in filling the inpatient medical record at the Ganesha Gianyar Hospital was highest in the correction item.
Highlights
an organization engaged in services
it is obliged to hold a medical record for the achievement of good administration
this is the process of organizing medical records
Summary
Rumah sakit merupakan suatu organisasi yang bergerak di bidang pelayanan kesehatan yang setiap hari berhubungan dengan pasien. Melayani pasien adalah salah satu bentuk pelayanan rumah sakit, maka dari itu rumah sakit memiliki kewajiban untuk menjalankan rekam medis dengan baik. Keperluan tersebut antara lain sebagai bahan bukti untuk dipengadilan, Pendidikan dan pelatihan, serta dapat digunakan untuk bahan evaluasi mutu pelayanan rumah sakit (Winarti & Supriyanto, 2013). Ketidaklengkapan informasi dalam pengisian rekam medis dapat menjadi masalah, karena rekam medis dapat memberikan informasi terinci tentang apa yang sudah terjadi kepada pasien selama berada di rumah sakit, hal ini pun berdampak pada mutu rekam medis serta terhadap pelayanan yang diberikan terhadap rumah sakit. Sedangkan jika mengacu pada pedoman standar pelayanan minimal (SPM) rumah sakit, terdapat empat indikator sasaran mutu yang salah satunya ketepatan waktu penyediaan dokumen rekam medis (Departemen Kesehatan Republik Indonesia, 2008). Berdasarkan uraian diatas, peneliti tertarik untuk melakukan penelitian tentang “Analisis Kelengkapan Pengisian Rekam Medis Rawat Inap Rumah Sakit Ganesha Di Kota Gianyar Tahun 2019”
Sign-in/Register to view highlights & summary Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
