塔朱丁·查利·马卡萨医生的玫瑰住院记录病人的医疗记录

Hasmah Hasmah, Musfirah Musfirah, Syamsiana Syamsiana
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引用次数: 0

摘要

病案档案管理是按照规定对病案档案进行汇总、完成填写(分析)、给出病码(编码)、标引分组(标引)、存储病案档案(填写)的活动。《卫生部长条例》,其中规定组织医疗记录的活动涉及向病人提供的所有医疗服务和行动,包括门诊、住院和急诊科。本研究旨在探讨麻瓦尔病区住院病案档案的管理。本研究采用定量研究方法和描述性方法进行。这项研究是在traddin Chalid Makassar医生的医疗记录装置进行的。人口和样本为93份病历文件。数据的呈现以分布表的形式完成,并在使用清单工具进行定量数据分析后附有解释。结果表明,汇编、分析和填充率低于80%,索引和编码率为100%。研究结果表明,组装、分析和填充均未达到医院服务质量标准。同时,编码和标引达到了医院服务的质量标准。建议增加和增加人员,特别是分析科和编码科的人员,尽管他们已达到医院服务的质量标准,但他们需要培训,并始终遵循与适用的疾病分类有关的社会化
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Pengelolaan Berkas Rekam Medis Pasien Rawat Inap Bangsal Mawar di RSUP Dr. Tadjuddin Chalid Makassar
Medical record file management is the activity of assembling and completing the filling (analysis) of medical record files and giving disease codes (coding), indexing grouping (indexing) and storing medical record files (filling) in accordance with the provisions. Regulation of the Minister of Health which stipulates that the activities of organizing medical records are carried out on all medical services and actions provided to patients, both outpatients, inpatients, and emergency departments. This study aims to determine the management of inpatient medical record files in the Mawar ward. The research was conducted using quantitative research methods with a descriptive approach. This research was carried out at the Medical Record Installation of Dr. Tadjuddin Chalid Makassar. The population and samples were 93 medical record files. The presentation of the data is done in the form of a distribution table accompanied by an explanation after going through quantitative data analysis using a checklist instrument. The results showed that assembling, analysis and filling were below 80%, while indexing and coding were 100%. The conclusion from the research is that assembling, analyzing and filling have not met the quality standards of hospital services. Meanwhile, coding and indexing have met the quality standards of hospital services. It is recommended that there be an increase and additional personnel, especially in the analysis section and for the coding section, even though they have met the quality standards of hospital services, they need training and always follow the socialization related to the applicable ICD
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