Analysis of Completeness of Filling in Medical Records and Time to Return Medical Records of Inpatients at Airlangga University Hospital
DOI:
https://doi.org/10.33746/fhj.v10i02.602Keywords:
completeness, accuracy, filling, returns, medical record, inpatientsAbstract
The implementation of medical records in hospitals can support the improvement of service quality through a fast and accurate documentation, so that the information produced is more effective and efficient. At Airlangga University Hospital, one of indicators of service that hadn’t been achieved was incompleteness of filling and returning medical record that exceeded 2x24 hours after service. The aim of the study was to analyze the implementation of filling and returning medical record for inpatients at Airlangga University Hospital. The research design was qualitative, using in-depth interview techniques with 30 main informants from doctors and nurses and 5 triangulation informants from assembling monitoring and medical record distribution officers. The results of the study illustrated that the implementation of filling and returning medical record was still lacking. In the input component, the doctor's activity and the number of items in the medical record caused incomplete filling. There was no reward and punishment policy from the hospital. In the process component, the incomplete medical records were found and the return of medical record wasn’t timely. In the output component, the most unfilled medical record forms were 58% informed consent and 33% doctor's signature. It was recommended that the hospital hold workshop about medical records and make policies related to reward and punishment.
Downloads
References
Al Aufa, B. (2018). Analisis Faktor Yang Berpengaruh Terhadap Ketidaktepatan Waktu Pengembalian Berkas Rekam Medis Rawat Inap Di Rs X Bogor. Jurnal Vokasi Indonesia, 6(2). https://doi.org/10.7454/jvi.v6i2.124
Depkes Ri, Dirjen Yanmed. (2006). Buku Pedoman Penyelenggaraan & Prosedur Rekam Medis Rumah Sakit Di Indonesia [depkes Ri, Dirjen Yanmed, 2006] [klzz813q97lg]. (n.d.). Retrieved July 13, 2023, from https://idoc.pub/documents/buku-pedoman-penyelenggaraan-prosedur-rekam-medis-rumah-sakit-di-indonesia-depkes-ri-dirjen-yanmed-2006-klzz813q97lg
Devhy, N. L. P., & Widana, A. A. G. O. (2019). Analisis Kelengkapan Rekam Medis Rawat Inap Rumah Sakit Ganesha Di Kota Gianyar Tahun 2019. Jurnal Rekam Medis Dan Informasi Kesehatan, 2(2), 106. https://doi.org/10.31983/jrmik.v2i2.5353
Febrianta, N. S., Insani, T. H. N., & Widyasari, F. (2020). Analisis Kelengkapan Pengisian Berkas Rekam Medis Rawat Jalan di Puskesmas Samigaluh 1 Tahun 2020. Jurnal Manajemen Informasi Dan Administrasi Kesehatan (JMIAK), 05(01), 69–76.
Oktavia, D. (2020). Analisis Ketidaklengkapan Pengisian Lembar Informed Consent Pasien Bedah di Rumah Sakit Tk. III dr. Reksodiwiryo Padang. Jurnal Manajemen Informasi Kesehatan Indonesia, 8(1), 24. https://doi.org/10.33560/jmiki.v8i1.246
Permenkes 269 Tahun 2008/Rekam Medis. (n.d.). Retrieved July 13, 2023, from http://www.pormiki-dki.org/2016-04-20-03-11-28/pp-pmk-uu/26-permenkes-269-tahun-2008-rekam-medis
Permenkes No. 24 Tahun 2022 tentang Rekam Medis [JDIH BPK RI]. (n.d.). Retrieved July 6, 2023, from https://peraturan.bpk.go.id/Home/Details/245544/permenkes-no-24-tahun-2022
Ramalenia, N. (2022). Perancangan Sistem Informasi Keluar – Masuk Berkas Rekam Medis Di Klinik Yakespen Utama Berbasis Visual Basic. JATISI (Jurnal Teknik Informatika Dan Sistem Informasi), 9(3), 2176–2190. https://doi.org/10.35957/jatisi.v9i3.2402
Sugiyono, P. D. (2019). Metode Penelitian Pendidikan: Pendekatan Kuantitatif, Kualitatif, R&D (Cetakan Ke 26). Bandung: CV Alfabeta, 1–334.
Suhartina, I. (2019). Analisis Kuantitatif Ketidaklengkapan Pengisian Resume Medis Berdasarkan Program Quality Assurance (Suatu Studi di Rumah Sakit Delta Surya Sidoarjo). Jurnal Kesehatan Vokasional, 4(2), 80. https://doi.org/10.22146/jkesvo.43948
View of Gambaran Sistem Penyelenggaraan Rekam Medis Di Rumah Sakit Umum Bunda Thamrin Tahun 2018. (n.d.). Retrieved July 6, 2023, from https://jurnal.uimedan.ac.id/index.php/JIPIKI/article/view/69/71
Wirajaya, M. K., & Nuraini, N. (2019). Faktor Faktor yang Mempengaruhi Ketidaklengkapan Rekam Medis Pasien pada Rumah Sakit di Indonesia. Jurnal Manajemen Informasi Kesehatan Indonesia, 7(2), 165. https://doi.org/10.33560/jmiki.v7i2.225
Downloads
Published
How to Cite
Issue
Section
License
Authors retain copyright and grant the journal the right of first publication. This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits use, distribution, and reproduction in any medium, provided the original author and source are properly cited.
