Detail Article

Administrasi dan Kebijakan Kesehatan

ISSN 1412-8853

Vol. 11 / No. 2 / Published : 2013-05

Order : 2, and page :60 - 65

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Original Article :

Improving medical record completeness

Author :

  1. Rumah Sakit Daerah Balung, Jember

Abstract :

The percentage of inpatient Medical Record data at Balung General Hospital showed 26.8% correct fulfillment,36.53% legal fulfillment, and only 48.61% complete data fulfillment which was below the target of the Ministry of Health(95%). The purpose of this study is to formulate a recommendation to improve the completeness of Balung GeneralHospital (BGH) inpatient Medical Record. The study design is observational using cross sectional way, and the instrumentis questionnaires. Samples employ doctors, nurses and administrative staff who are in charge of fulfilling the inpatientmedical record amounting to 77 people. Descriptive data analysis was used and the result was followed up with a FocusGroup Discussion to formulate a recommendation for improving the completeness of the inpatient medical record. Resultrevealed that data fulfilling in BGH inpatient medical record was poor due to the influence of fulfilling process of allprofession types, to the low procedural knowledge and to the low knowledge of medical record pathway. Medical recordfulfilling result was not influenced by the medical record forms: availability, clarity, easiness to fulfill, appropriateness,and time-to-fulfill. One of the recommendations to improve the completeness of medical record fulfilling is to train themedical record staff on how to fill the medical record in proper and correct ways.

Keyword :

medical record, completeness, recording process,

References :

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Halim, P,(2008) Hubungan Penghargaan (Reward) dengan Motivasi Dokter dalam Pengisian Rekam Medis di RSUD Sidikalangn tahun 2008 Medan : FKM USU

Koagouw, Maria, Hari Kusnanto, Andreasta Meliala.,(2004) Efek Himbauan Pelatihan Terhadap Kelengkapan Rekam Medis Pasien Rawat Inap di RSU Pancaran Kasih GMIM Manado Yogyakarta : lmu Kesehatan Masyarakat

Kusnanto, Hari.,(1996) Rekam Medis dan Informasi Kesehatan. Kursus Mahir Perekam Medis Profesional. Yogyakarta : Program Magister Manajemen Rumah Sakit UGM

Mariana, Dina.,(2009) Analisis Kelengkapan Rekam Medis Rawat Jalan Psikiatri RS. Dr. H. Marzoeki Mahdi Bogor Periode Januari–Mei 2009 Jakarta : FKM UI

Ratmanasuci, R,(2008) Analisis Kelengkapan Pengisian Dokumen Rekam Medis Rawat Inap di RSUD Kota Semarang Tahun 2008 Semarang : FKM UNDIP

Archive Article

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