Quantitative Analysis Of Completeness Of Medical Record Document Filling At Public Health Center

Healthy-Mu Journal Pub Date : 2022-05-10 DOI:10.35747/hmj.v5i2.222

Galih Persadha

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Abstract

Completeness of filling out medical record documents is a must that must be fulfilled to improve the quality of service quality in health care institutions. The community health center is a first-level individual health service facility, by prioritizing promotive and preventive efforts in its working area. Improvement efforts are carried out by conducting regular reviews, both qualitative and quantitative. The quality of the medical record document is reflected in the completeness status if it meets the criteria: completeness of content, accuracy, timeliness and compliance with legal aspects. In the preliminary study, it was found incompleteness in filling out medical record documents. In the Authentication Review found incompleteness that can reduce or even eliminate the value of medical record documents both financially, therapy continuity and law. This study aims to assess the completeness of filling out medical record documents by using quantitative analysis methods on the completeness of filling out medical record documents. The research method used is descriptive with a quantitative approach. The sample in this study was 20 medical record documents from public health centers which were taken randomly using random sampling method from two different public health centers. The results showed that the Patient Identification Review, the Important Reporting Review, the anamneses were 100% complete, the Authentication Review was 87.5% complete and the Correct Documentation Review was 82% complete. The conclusion obtained is that the Authentication Review section of the doctor's name is 79%, the signature of the doctor or nurse is 96% and in the Correct Documentation Review in the section there are scribbles of 12.5%, the use of type-x is 4% and there is an empty section of 37.5 %. Efforts made to improve the quality of the completeness of medical record documents can be carried out by evaluating the implementation of the established SOP and reviewing the provision of rewards and punishments

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公共卫生中心病案填写完整性的定量分析

病历文件填写的完整性是提高医疗机构服务质量的必要条件。社区保健中心是一级个人保健服务设施，在其工作区域优先开展促进和预防工作。通过定期进行定性和定量审查来进行改进工作。病历文件的质量反映在其是否符合以下标准:内容完整、准确、及时性和符合法律规定。在初步研究中，发现病案文件填写不完整。在认证审查中发现的不完整性可能会降低甚至消除病历文件在财务、治疗连续性和法律方面的价值。本研究旨在通过对病案文件填写完整性的定量分析方法，评估病案文件填写完整性。使用的研究方法是定量的描述性方法。本研究的样本为20份公共卫生中心的病历文件，采用随机抽样的方法在两个不同的公共卫生中心随机抽取。结果显示，患者身份审核、重要报告审核、病历审核的完成率为100%，认证审核完成率为87.5%，正确文献审核完成率为82%。得出的结论是，医生姓名的认证审查部分占79%，医生或护士的签名占96%，正确文件审查部分的涂鸦占12.5%，使用类型x占4%，空白部分占37.5%。通过对既定SOP的执行情况进行评估，并对奖惩的规定进行审查，提高病案文件完整性的质量

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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Healthy-Mu Journal

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