Analisis Kelengkapan Pengisian Berkas Rekam Medis Pasien Rawat Inap RSUP Dr. Kariadi Semarang

ARTERI : Jurnal Ilmu Kesehatan Pub Date : 2019-11-13 DOI:10.37148/arteri.v1i1.20

Selvia Juwita Swari, Gamasiano Alfiansyah, Rossalina Adi Wijayanti, Rowinda Dwi Kurniawati

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引用次数: 18

Abstract

The completeness of medical record file in December 2018, January 2019 and February 2019 is not complete, so it does not Fulfill the Minimum Standards of Hospital Services. The incomplete filling of medical record files will cause the records to be out of sync and the patient's previous health information difficult to identify. The purpose of the study was to identify the completeness of filling medical record files and the factors causing incompleteness of filling medical record files for inpatients at RSUP Dr. Kariadi Semarang. This research was a qualitative research. The research subjects consisted of 2 officers in charge of medical records. The object of the study was 86 samples of inpatient medical record files from 25-28 February 2019 based on the Slovin formula. The results of the research that the completeness of the patient's identity, the completeness of important reports, the completeness of inpatient medical record file authentication and the completeness of correct recording, indicated that the completeness of filling the medical record was quite high. The incompleteness of filling in the inpatient medical record file was caused by several factors, specifically the officer factor (man), procedural factor (method), tool factor (material), machine factor and motivation factor.

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分析完成了住院病人记录的病史

2018年12月、2019年1月、2019年2月病案档案完整性不完整，不符合医院服务最低标准。病历文件填写不完整会导致病历不同步，患者以前的健康信息难以识别。本研究的目的是确定住院病人病历档案填写的完整性和导致病历档案填写不完整的因素。本研究为定性研究。研究对象为2名病案管理人员。该研究的对象是根据斯洛文公式从2019年2月25日至28日的86份住院病历文件样本。从患者身份的完整性、重要报告的完整性、住院病案档案认证的完整性、正确记录的完整性等方面的研究结果表明，住院病案填写的完整性较高。住院病案档案填写不完整的原因主要有人员因素(人)、程序因素(方法)、工具因素(材料)、机器因素和动机因素。

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ARTERI : Jurnal Ilmu Kesehatan

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