THE MANAGEMENT OF MEDICAL REPORT COMPLETENESS FOR THE LEGALITY OF MEDICAL RECORD DOCUMENTS AT RSUD KRMT WONGSONEGORO (RSWN) SEMARANG CITY

VISIKES: Jurnal Kesehatan Masyarakat Pub Date : 2021-10-04 DOI:10.33633/visikes.v20i2.5069

S. Suyoko

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Abstract

ABSTRACTBackground: Quality hospital services is reflected in the achieving of medical records. Improper medical record documentation would negatively affect the quality of service delivered to patients and it would disadvantage the hospital when medical disputes occur.Objective:Analyzing the management of medical record completeness at RSWN to guarantee the legality of medical record documents and its effect in supporting the completeness of medical record documents.Method:In this qualitative research, observation and interviews were conducted to 60 PJRM officers in the Arimbi ward, Banowati, Nakula I and Prabukresna. The obtained data were qualitatively and quantitatively analyzed based on several underlying theories.Results:The results showed that the completeness of some aspects includinghuman, money, method, material and machine elements was proper. The quantitative analysis showed 100%, while the qualitative analysis showed a percentage of 100% with the exception on the informed consent component with the potential for loss of 99%.Conclusions:The human element required periodic outreach to PPA. In the machine element, special computerswere needed for PJRM officers, and the importance of informed consent for patients undergoing hemodialysis to obtain medical records with strong legal force. Key Words :Management, Medical Record Completeness, Legality of Medical Records.

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三宝垄市医疗报告完整性管理对病历文件合法性的影响

摘要背景:医院服务质量体现在病案的实现上。不当的病历文件会对提供给患者的服务质量产生负面影响，并在发生医疗纠纷时对医院不利。目的:分析医院病案完整性管理，以保证病案文件的合法性，并分析其在支持病案文件完整性方面的作用。方法:采用定性研究方法，对Arimbi区、Banowati区、Nakula I区和Prabukresna区的60名PJRM官员进行观察和访谈。根据几个基本理论对获得的数据进行定性和定量分析。结果:实验结果表明，在人、钱、法、料、机等方面的完备性是合理的。定量分析显示为100%，而定性分析显示为100%，但知情同意部分例外，潜在损失为99%。结论:人的因素需要定期延伸到PPA。在机器方面，PJRM官员需要专用计算机，并且对接受血液透析的患者进行知情同意的重要性具有很强的法律效力，以获得医疗记录。关键词:管理、病历完整性、病历合法性

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VISIKES: Jurnal Kesehatan Masyarakat

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