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Analisis Kelengkapan Pengisian Berkas Rekam Medis Pasien Rawat Inap RSUP Dr. Kariadi Semarang Swari, Selvia Juwita; Alfiansyah, Gamasiano; Wijayanti, Rossalina Adi; Kurniawati, Rowinda Dwi
ARTERI : Jurnal Ilmu Kesehatan Vol 1 No 1 (2019): November
Publisher : Puslitbang Sinergis Asa Professional

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (839.834 KB) | DOI: 10.37148/arteri.v1i1.20

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.
Design of Emergency Medical Record Form Based On Hospital Accreditation Standard Version 2012 in Hospital “X” Deharja, Atma; Swari, Selvia Juwita; Esti, Dyah Eriyaning
JMMR (Jurnal Medicoeticolegal dan Manajemen Rumah Sakit) Vol 6, No 3 (2017): December
Publisher : Universitas Muhammadiyah Yogyakarta in Clollaboration with ADMMIRASI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.18196/jmmr.6142

Abstract

Based on pre-survey in Balung General Hospital, showed that emergency form has not qualified with hospital accreditation standard (version 2012) for an early medic and nursing assessment. The aim of this research is to re-design emergency forms based on hospital accreditation standard  (version 2012) in Balung General Hospital. This research is a qualitative study with observation, interview, and brainstorming. The result of this research is viewed from the physical aspect of the emergency form using white paper in size of A4 80 gram in portrait layout. Based on anatomy aspect, the form heading is to put the logo, the name and the full address of the instance, the introduction which should be appropriate with the aim of the form that is the early medic and nursing assessment. Based on the content aspect of the emergency form, the additional data consists of a kind of triage, the date of arrival and handling, painful scale, medicine allergic and fall down risk. Based on the nursing assessment form, it consists of patient's identity, primary survey, secondary survey, nursing diagnose, action plan, self nurse-act, nursing evaluation, further action, given tasks and nurse authentication. Hopefully, the researcher's suggestion related to the result of emergency form design can be applied in Balung General Hospital, Jember.