Surya Medika: Jurnal Ilmiah Ilmu Keperawatan dan Ilmu Kesehatan Masyarakat
Vol 17, No 2 (2022)

Gambaran Kelengkapan Resume Rekam Medis Pasien Rawat Jalan

Ni Nyoman Novia Marheni (Sekolah Tinggi Ilmu Kesehatan Wira Medika Bali)
Ni Luh Putu Devhy (Sekolah Tinggi Ilmu Kesehatan Wira Medika Bali)
Made Wahyu Aditya (Sekolah Tinggi Ilmu Kesehatan Wira Medika Bali)



Article Info

Publish Date
05 Jul 2022

Abstract

Background of Study: One of the parameters to determine the quality of health services in hospitals is data or information from good and complete medical records. Indicators of good and complete medical record quality are content completeness, accuracy, timeliness, and compliance with legal requirements. This study aims to determine the completeness of outpatient medical records at the Wangaya Regional General Hospital.Methods: The number of samples in this study were 30 inpatient medical records obtained using the slovin formula. The sampling technique used in this study was probability sampling method with a simple random sampling technique. This research was conducted for 2 months from January-February 2021, and data analysis using SPSS.Results: From the results of the research conducted when viewed from several aspects, it was found that Based on the Identification Review, there were 33.3% incomplete, namely in filling in the telephone number. Based on the reporting review, there were 56.7% incomplete, namely in filling out treatment/ therapy and 40% incomplete in filling out physical examination. true or understandable. Based on 100% complete Authentication Review, there was the doctor's name and signature. Based on the results obtained, it can be concluded that the writing of medical records was not 100% complete.Conclusion: It is hoped that the Wangaya Regional General Hospital can improve the completeness of filling out outpatient examination forms by holding training, workshops related to the importance of filling out complete medical records.Keywords: Medical Record, Outpatient, Description Completeness

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Journal Info

Abbrev

SM

Publisher

Subject

Medicine & Pharmacology Nursing Public Health

Description

Jurnal Surya Medika adalah jurnal yang diterbitkan oleh STIKes Surya Global Yogyakarta. Jurnal ini Fokus pada Ilmu Kesehatan yang meliputi: Ilmu keperawatan, kesehatan masyarakat, farmasi dan yang sebidang dengan kesehatan. Jurnal ini terbit dua kali dalam satu tahun yaitu pada bulan Januari dan ...