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All Journal Jurnal Ilmiah Kesehatan Masyarakat
Nabilah Khairunisa
Universitas Esa Unggul
Dentistry Health Professions Medicine & Pharmacology Nursing Public Health Veterinary

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Tinjauan Kelengkapan Rekam Medis Rawat Inap di Rumah Sakit Umum Daerah Kembangan Nabilah Khairunisa; Dina Sonia; Puteri Fannya; Noor Yulia
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 4 (2023): Oktober 2023
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/sehatmas.v2i4.2403

Abstract

The completeness of filling in the medical record can be checked using a documentation audit, one of which is quantitative analysis by reviewing certain parts of the contents of the medical record with the intention of finding deficiencies, especially those related to medical record documentation. The purpose of this study was to get an overview of the completeness of filling out inpatient medical records at the Kembangan Regional General Hospital. This research method uses a descriptive method with a quantitative approach. The population in this study were inpatient medical records at the Kembangan Regional General Hospital with a sample of 89 medical records. Based on the results of calculations using quantitative analysis obtained an average completeness of 82%, the highest completeness is the patient identification component of 87% and the lowest completeness is the important reporting component of 76%. Based on the research that has been done, it can be concluded that filling in the medical record at the Kembangan Regional General Hospital is not complete, this is due to the lack of awareness of health workers to complete filling in the medical record so that it has an impact on incomplete filling in medical record files
Co-Authors Dina Sonia Noor Yulia Puteri Fannya