Bali Medika Jurnal
Vol 9 No 3 (2022): Bali Medika Jurnal Vol 9 No 3 Desember 2022

Factors Affecting the Completeness of Completion of Inpatient Medical Records in Hospitals: Factors affecting the completeness of hospitalizationmedical records: a literature review

Ni Luh Putu Devhy (STIKes Wira Medika Bali)
Ika Setya Purwanti (STIKes Wira Medika Bali)



Article Info

Publish Date
30 Dec 2022

Abstract

Medical record is a document that contains patient data consisting of identity, history of examination and treatment of patients. Medical records must be filled out completely because they can be used as a legal basis if something unexpected happens during a health action. Completeness of medical records can be used as a support to improve health services. Based on the results of previous studies, it was found that only 74% of the completeness of the RM from the name of the action indicator. This literature review aims to determine the factors that affect the completeness of filling out medical records. Methods: The method used in this article is a literature review, the search for articles in this LR uses a google scolar, with the keywords "completeness factors", AND "medical records" AND "hospitalization". The articles found in the search were 262 articles, then re-evaluated according to the inclusion and exclusion criteria that had been set so that finally 5 articles were available that could be reviewed. Results: Factors that affect the completeness of filling out medical records are man, method, material, money Man, money and methode are factors which effect uncomplitement of medical records, so that recommended to make standard operating procedure (SPO) in doing medical records then for giving motivation to the health worker in filling medical records we can giving present and clear sanctions for them. Conclusion: Man, money, materials, and methods are factors that can affect the incompleteness of medical records, so it is recommended to make Standard Operating Procedures (SOP) in carrying out medical record activities and socialize them on an ongoing basis, then to motivate health workers in filling out RMs, prizes can be given and clear sanctions.

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Journal Info

Abbrev

bmj

Publisher

Subject

Health Professions Nursing Public Health

Description

BMJ bertujuan memprakarsai dan merangsang penelitian berdampak tinggi dan inovatif yang relevan bagi akademisi dan praktisi di industri kesehatan. Audiensi publikasi ini utamanya terdiri dari akademisi, mahasiswa pascasarjana, praktisi dan semua yang tertarik pada bidang penelitian kesehatan. Jurnal ...