Jurnal Admmirasi
Vol 5 No 1 (2020): June

Analisis Kepatuhan Petugas Klinis Dalam Kelengkapan Rekam Medis Elektronik dan Rekam Medis Manual Di Rumah Sakit

Muhlizardy Muhlizardy (Unknown)



Article Info

Publish Date
22 Jun 2020

Abstract

The completeness of the medical record can accurately provide information that can be used as a reference for health services, legal basis, support information to improve medical quality, medical research and be used as a basis for assessing hospital performance. The purpose of this study was to determine differences in clinical officer compliance in completeness of electronic medical records and manual medical records with primary cardiac diagnoses in hospitals. The design of this research is descriptive quantitative with a retrospective design. Data was taken from 30 samples of manual medical records and 30 samples of electronic medical records. The data collection method is in the form of a checklist. While the analysis of the data used is univariate and bivariate analysis with the Mann-Whitney U Test. The results showed that complete manual medical records were 13.3%. The most complete aspects are CPPT and HHC. Whereas in complete electronic medical records as much as 56.7% of medical records. The most complete aspects of completeness are the initial nursing assessment, fall assessment, pain assessment, nursing action and nursing plan. While the statistical results using the Mann-Whitney U Test show that there are several aspects that have a statistically significant comparison. These aspects include initial nursing assessment (p = 0.001), fall assessment (p = 0.001), pain assessment (p = 0,000), nursing plan (p = 0,000), nursing actions (p = 0,000), CPPT (p = 0,000), = 0,000), educational records (p = 0,000), discharge planing (p = 0.005), HHC (p = 0,000), drug administration records (p = 0.019) and drug reconciliation (p = 0,000). Statistically it was concluded that there were significant differences between manual and electronic medical records with a p-value <0,000.

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Journal Info

Abbrev

admmirasi

Publisher

Subject

Economics, Econometrics & Finance

Description

ISSN: 2685-8142 (Online) ISSN: 2477-6947 (cetak). JURNAL ADMMIRASI berfokus pada penelitian dan tinjauan penelitian terkait dengan manajemen rumah sakit yang relevan untuk pengembangan teori dan praktik manajemen rumah sakit di Indonesia dan Asia Tenggara. JURNAL ADMMIRASI mencakup berbagai ...