Jurnal Info Sains : Informatika dan Sains
Vol. 13 No. 02 (2023): Jurnal Info Sains : Informatika dan Sains , Edition September  2023

Qualitative Study of Determinants of Medical Record Completeness of Inpatients at Dr. Hadrianus Sinaga Hospital in 2023

Lasrina E. Tambun (Universitas Sari Mutiara Indonesia)
Rahmat Alyakin Dachi (Universitas Sari Mutiara Indonesia)
Janno Sinaga (Universitas Sari Mutiara Indonesia)



Article Info

Publish Date
30 Sep 2023

Abstract

Medical records are files that contain records and documents about patient identity, examination, treatment, actions and other services that have been provided to patients. Medical records must be kept either electronically or in writing that is clear and concise. Medical record documents that have been completed by the doctor within less then 24 hours after completion of the service or after the inpatient is decided to go home. This research is a qualitative research. The research instrument is the researcher himself who is subjective, so the data obtained is checked for validity using triangulation techniques, namely source triangulation, technical triangulation and time triangulation. Informants are the Doctor in Charge, Nurse, Midwife, Head of Medical Records Installation and hospital management, namely the Head of Nursing and Midwifery Services Section. Interviews were conducted according to Esterberg and literature studies. The results showed that the determinants of the completeness of Medical Record files were influenced by Man, namely the indiscipline in filling out Medical Record files, Machine, namely the absence of a policy from management if human resources was not disciplined in filling out Medical Record files, Method, namely the lack of motivation in filling in accordance with the SOP, Material, namely sometimes slow provision of parts Medical Record dan Money forms, that is there is no reward dan punishment if the Medical Record is complete.

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Journal Info

Abbrev

InfoSains

Publisher

Subject

Computer Science & IT

Description

urnal Info Sains : Informatika dan Sains (JIS) discusses science in the field of Informatics and Science, as a forum for expressing results both conceptually and technically related to informatics science. The main topics developed include: Cryptography Steganography Artificial Intelligence ...