IDENTIFIKASI KETIDAKLENGKAPAN REKAM MEDIS PASIEN RAWAT INAP RUMAH SAKIT MUHAMMADIYAH LAMONGAN
ABSTRACT: The fulfillment
completeness of medical record in Muhammadiyah hospital is very poor. The study
aimed to identify the
precaution of incompleteness fulfillment
of medical record
in the inpatient
of Muhammadiyah hospital lamongan.
This was a
descriptive study with
observational and cross
sectional design. The
population was all file of inpatient medical record. Observations were
hold in 94 medical record files of 7 inpatient rooms.This study include
interview with the
officer of medical
record to complete
the result of
this study. The
result of the study
showed that the
fulfilment completeness of
medical record file
had different performance.
Standard operating procedure; job description; reward and punishment regulating the medical record
fulfillment were very good. In other
side, the evaluation
of medical record
filling process was
also in very
good category. Although, monitoring in filling process was
not implemented. This study concluded that the determinant of inpatient medical
record fulfillment incompleteness in
Muhammadiyah hospital is the failure
of fulfilment monitoring.
This study suggests that should
be more routine medical record filling process monitoring.
Penulis: Dian Mawarni, Ratna
Dwi Wulandari
Kode Jurnal: jpkedokterandd130181
