急救医院手术报告表病历完整性审核

Nirma Alfiani, Dede Setiawan, Sumarni
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引用次数: 0

摘要

医疗记录作为保健服务的证据,在证明法律方面具有重要作用,包括在每一项中具有特定功能和含义的医疗记录形式。其中之一是手术报告,这是一个永久的或永久的医疗记录的内容。本研究的目的是更深入地了解cirbon Regency的Sumber Waras医院手术报告表上医疗记录的完整性。使用的研究类型是描述性研究。数据收集技术采用观察法,配有研究仪器清单。简单的随机抽样技术。本研究样本为锡雷邦区源瓦拉斯医院手术患者病历多达72份的病历文件。业务报告表中的医疗记录结果有11个文件(15%)完全保存,61个文件(85%)没有完全保存。本研究得出的结论是,Cirebon Regency的Sumber Waras医院的最低病案服务标准不符合2008年Kepmenkes号129。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
REVIEW OF MEDICAL RECORD COMPLETENESS ON THE OPERATION REPORT FORM AT SUMBER WARAS HOSPITAL, CIREBON REGENCY
Medical records as evidence of health services have an important role in proving law including forms on medical records that have specific functions and meanings in each item. One of which is an operating report that is the contents of an everlasting or perpetuated medical record. The purpose of this research is to know a deeper overview of the completeness of the medical record on the Operation report form at the Sumber Waras Hospital of Cirebon Regency.  The type of research used is descriptive research. Data collection techniques using an observation method with the research instrument sheet Checklist. Simple random sampling techniques. The sample in this study is the medical record of the operating patients in the Cirebon district source Waras Hospital as much as 72 medical record documents.  The results of the medical record in the Operations report form there are 11 documents (15%) a fully stocked and 61 documents (85%.) that are not fully stocked.  The conclusion obtained in this study is that the minimum medical record service standard at Sumber Waras Hospital in Cirebon Regency is not in accordance with Kepmenkes number 129 of 2008.
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