Caecilia Indarti
Department Of Dental Public Health, Faculty Of Dentistry, Hang Tuah University

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Analysis of Medical Record Document Filling Completeness of Outpatient at Nala Husada Dental Hospital Caecilia Indarti; Lita Agustia
Insisiva Dental Journal: Majalah Kedokteran Gigi Insisiva Vol 11, No 2 (2022): November
Publisher : Universitas Muhammadiyah Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.18196/di.v11i2.16077

Abstract

Medical records (RM) as patient health information recorded assessment results, plans and implementation of care, treatment, integrated patient progress, as well as a summary of discharge for inpatients made by PPA. The results of medical record documents tracing at the Nala Husada dental hospital found that the RM was incomplete. This study aims to analyze the completeness of medical records filling that does not align with the accreditation standard of medical records management and health information (MRMIK). This study identified causal factors as a follow-up to implementing patient medical record management. It was conducted quantitatively with a descriptive observational approach. Data was obtained through observation, interviews, and documentation at the medical record unit during July 2022. The data was then processed and analyzed. Based on the analysis of the completeness of the 80 file documents, 86.25% were found to be complete, and 13.75% were incomplete. Incomplete medical record documents with good records were 17.4%, 16% important reports/records, 12.5% author authentication, and 8% patient identity. Factors causing incomplete filling of medical record documents with the management element approach included human error (lack of understanding and discipline, limited number of staff, training), Material and Machine (limited equipment, various documents, unspecific evaluation monitoring review), and method (incomplete regulatory studies), monitoring and evaluation are not continuous), and money (not included in the program budget plan). Recommendations to improve the completeness of medical record filling were training, sanctions, and rewards, regulation review, procedures for filling as per PPA requirements, and standardization of medical record forms.
E-Knowledge Module Development with Sprint Method in Dr. Ramelan Navy Hospital Caecilia Indarti; Siti Saerah; Djazuli Chalidiyanto
Denta Journal Kedokteran Gigi Vol 16 No 2 (2022): Agustus
Publisher : Fakultas Kedokteran Gigi Universitas Hang Tuah

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.30649/denta.v16i2.4

Abstract

Background: Hospitals need to manage document systems well. Dr Ramelan Navy hospital  only 15% of the training materials have been documented. Knowledge of basic infection control programs only reached 57.2% and effective communication reached 56%. Objective: The purpose of this study is to analyze the factors causing the documentation of training materials under the standard, to determine solutions to improve the documentation of training materials to reach the standard and to develop an activity plan in overcoming the problem of documentation of training materials that have not reached the standard. Methods: This study uses the analytical observational method. The method used is the Problem Solving Cycle (PSC) approach. Data obtained through interviews, observations, and documentation in several departments and work units, then processed through a number of stages in overcoming the problem of documentation of training materials. Problems are solved by using a problem solving cycle approach with five stages of problem analysis, strategy design, development strategy, implementation, monitoring, evaluation and feedback. Solution of problems with the development of knowledge modules in hospital management information system. Results: The results at the strategy development stage of the development of the module named E-Knowledge was developed using the Sprint method with five stages of map, sketch, divide, prototype and test. Conclusion: E Knowledge increase knowledge and improve personnel performance.