J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan
Vol 4 No 2 (2023): March

Analisis Kelengkapan Pengisian Berkas Rekam Medis

Fahrunisa Fahrunisa (Politeknik Medica Farma Husada Mataram)
Musparlin Halid (Politeknik Medica Farma Husada Mataram)
Ikhwan Ikhwan (Politeknik Medica Farma Husada Mataram)



Article Info

Publish Date
24 Feb 2023

Abstract

Minimum Service Standards (MSS) indicators in the form of completing the filling of medical record documents for 24 hours. There are medical record files and informed consent that are incomplete and not in accordance with MSS. The purpose of the study was to identify and analyze the completeness of the medical record file. The study was conducted at the Hospital of NTB Province. The purpose of the study was to determine the level of completeness of the contents of the medical record document. This research uses quantitative type. The sample is 87 medical record files. Services in the medical record section are not in accordance with the MSS. With details of the completeness of the contents of the medical record document for 24 hours after the service, it has not been completely filled out, such as the initials of the doctor/nurse (62%). Indicators of filling out informed consent from completeness after the patient is given incomplete information, such as providing information (76%), type of information (76%), doctor's signature (76%), and signatures of witnesses 1 and 2 (76%). The medical record document has not been filled in completely by the medical record officer.

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Journal Info

Abbrev

j-remi

Publisher

Subject

Health Professions Public Health

Description

J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan is a scientific journal that is managed and published by the Program Studi Rekam Medik, Jurusan Kesehatan, Politeknik Negeri Jember. J-REMI contains the publication of research results from students, lecturers and or other practitioners in the ...