Overview of the Implementation of Incomplete Control of Medical Record Documents at Sentosa Baru Health Center in 2023
Keywords:
Handling Medical Records, IncompletenessAbstract
One of the implementations of controlling medical record documents is by completing medical record documents properly in accordance with SOPs. This study was shown to determine the implementation of medical record document control at Sentosa Baru Health Center. This research is a Quantitative descriptive research. The method used in this study is by Observation. The research was conducted at Sentosa Baru Health Center. The study was conducted from June to August 2023. The population at Sentosa Baru Health Center is 780 medical record documents The sample size in this study was calculated based on the slovin formula so that 80 medical record documents were obtained as research subjects. For the completeness of medical record documents, in the section of writing patient identity, name, time, doctor's signature, there are 80 medical record documents completely (100%). The column of date, month, year, justification for writing medical records there are 40 complete medical record documents (50%) and in the writing section of Assessment, Planning, Screening-vital sign there are 60 complete medical record documents (75%). Thus, the author suggests to the medical record officer at Sentosa Baru Health Center, to re-socialize related to the SOP by filling out medical record documents and then evaluating the suitability between the SOP and the performance of the medical record officer.
References
R. Kemenkes, Peraturan Menteri Kesehatan Nomor 55 Tahun 2013 tentang Penyelenggaraan Pekerjaan Perekam Medis. 2009.
Rini, “Rekam medis berisi tentang semua tindakan terhadap pasien rawat jalan di puskesmas,” 2019.
Depkes, “Departemen kesehtan peraturan menteri kesehtan republik indonesia,” 2014.
H. Yuliastuti, “Tinjauan Pelaksanaan Assembling Dalam Pengendalian Ketidaklengkapan Berkas Rekam Medis Di Rsu Muslimat Ponorogo,” J. Delima Harapan, vol. 7, no. 1, pp. 39–47, 2020, doi: 10.31935/delima.v7i1.94.
Maimun and I. Sari, “Analisis Deskriptif Kelengkapan Dokumen Rekam Medis Di Poli Rawat Jalan Kia Rsupn Dr. Cipto Mangunkusumo,” J. Kesehat., vol. 10, no. 1, pp. 13–24, 2022, doi: 10.35913/jk.v10i1.244.
D. Fadilah, “Analisis faktor penyebab ketidaklengkapan rekam medis pasien rawat inap di puskesmas kotaanyar kabupaten probolinggo,” 2020.
S. Amelia, “Tinjauan Pelaksanaan Assembling Dalam Pengendalian Ketidaklengkapan Berkas Rekam Medis Rawat Inap Di Puskesmas Tanah Merah,” Naskah Publ., 2021.
A. Sahira, “tinjauan pelaksanaan assembling dalam pengendalian ketidak lengkapan berkas rekam medis rawat inap di puskesmas tanah merah tahun 2021,” 2021.
Dr ms Muhammad thabran talib skm mars, manajemen rekam medis si jantung rumah sakit. 2022.
W. Wahyudi, “Analisis Motivasi Belajar Siswa Dengan Menggunakan Model Pembelajaran Blended Learning Saat Pandemi Covid-19 (Deskriptif Kuantitatif Di Sman 1 Babadan Ponorogo),” KadikmA, vol. 13, no. 1, p. 68, 2022, doi: 10.19184/kdma.v13i1.31327.
Notoatmodjo, “METODOLOGI PENELITIAN,” 2018, 2018.
Sugiyono, “Defenisi Operasional variabel penelitian,” 2015.
A. Abdul, “Teknik Analisis Data Analisis Data,” Tek. Anal. Data Anal. Data, pp. 1–15, 2020.
Sugiono, “Analisis Perubahan Hemodinamik,” Skripsi STT Kedirgant. Yogyakarta, pp. 34–50, 2021.
E. A. Agustina, “Faktor Penyebab Ketidaklengkapan Pengisian Dokumen Rekam Medis Rawat Inap di Rumah Sakit: Literature Review,” J. Manaj. Inf. Kesehat. Indones., vol. 10, no. 1, p. 104, 2022, doi: 10.33560/jmiki.v10i1.403.
