Analisis Kelengkapan Rekam Medis Rawat Inap Rumah Sakit Ganesha Di Kota Gianyar Tahun 2019

Jurnal Rekam Medis dan Informasi Kesehatan Pub Date : 2019-10-25 DOI:10.31983/jrmik.v2i2.5353

Ni Luh Putu Devhy, Anak Agung Gede Oka Widana

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引用次数: 2

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.

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这是2019年詹亚尔甘尼萨住院记录的分析

医院是一个服务性组织，因此有义务保存病案，以实现良好的管理。登记、数据填写、处理和分析以及文件编制，这是病历组织的过程。如果病历表上的每一项都填满了完整的数据，那么填写病历就是好的。一份完整的病历是医院的高质量形象。基于以上背景，研究者想要了解Gianyar市Ganesa医院住院患者病历填写的完成率。这种类型的研究是具有横断面设计的描述性研究。本研究的样本为95份住院病历文件。RM患者身份完成率为100%，医生身份完成率为96.8%，护士身份完成率为85.3%，知情同意完成率为95.8%，麻醉完成率为43.2%，简历完成率为100%，诊断完成率为100%，缩略语完成率为66.3%，可读性为76.8%，整改完成率为23.2%，结构化完成率为100%。Ganesha Gianyar医院住院病历填写不完整在纠正项目中是最高的。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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Jurnal Rekam Medis dan Informasi Kesehatan

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