Analisis Sistem Pengelolaan Resume Medis Rawat Inap Di Rumah Sakit Umum Muhammadiyah Babat
Abstract
A medical record is a summary of the entire treatment and care period a patient
undergoes while receiving medical attention at a hospital. Incomplete medical
records result in a lack of information about the patient's condition, which can
adversely affect various concerned parties. The aim of this study is to analyze the
inpatient medical records at Muhammadiyah General Hospital Babat by identifying
the completeness of these records. The research design employed is a descriptive
quantitative method. The study was conducted from February to August 2023. The
population of this study comprises all inpatient medical record files from February to
March 2023, totaling 487 medical record files. The sampling technique employed is
total sampling. The variable of this research is the Completeness of Inpatient Medical
Record Filling. Based on the research findings, it can be elucidated that there are two
main categories within medical records: complete and incomplete medical records.
From the available data, it is revealed that the percentage of complete medical
records, as indicated, is 76%. Conversely, data also reveals that 24% of the sampled
medical records do not meet the expected level of completeness. This incompleteness
is attributed to various indicators, including primary complaints, diagnosis,
treatment/procedures, supporting examination results, encountered problems,
discharge conditions, prognosis, causes of death, and proposed follow-up actions. To
address this issue, the researchers anticipate a focus on enforcing adherence to
medical record filling through continuous dissemination to healthcare personnel
responsible for completing the medical records. Standard operating procedures,
training, and reward-punishment mechanisms are suggested approaches
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