Keywords
form filling
Operation Case
How to Cite
Abstract
Based on the results of observations made at Pertamina Central Hospital, it was found that several inpatient medical record file forms, especially in cases of surgery, were related to filling out forms that were not 100% complete and there was no evaluation of the completeness of inpatient medical record files in surgical cases. The purpose of this study was to analyze the completeness of inpatient medical record files, especially cases of surgery at Pertamina Central Hospital in February 2022. This research method used qualitative descriptive. Sampling using the Slovin formula with a population of 200 and the sample results obtained 67 samples. The results of this study obtained that the completeness of filling out the medical record file operation form in the complete category was 43 medical record files (64%) and 24 medical record files were incomplete (36%). The conclusion of this study is that the completeness of inpatient medical record files in surgical cases, especially related to filling out forms at Pertamina Central Hospital is categorized as incomplete because filling out forms is not 100% complete.
References
D. Yanmed, “Petunjuk Teknis Pengadaan Formulir Rekam Medis Dasar dan Pemusnahan Arsip Rekam Medis di Rumah Sakit,” 1995.
PERMENKES RI No 269/MENKES/PER/III/2008, “permenkes ri 269/MENKES/PER/III/2008,” Permenkes Ri No 269/Menkes/Per/Iii/2008, vol. 2008. p. 7, 2008.
Kemenkes, “6 KMK No. 129 ttg Standar Pelayanan Minimal RS.pdf,” 129. 2008.
D. N. L. Putu and A. A. G. O. Widana, “Analisis Kelengkapan Rekam Medis Rawat Inap Rumah Sakit Ganesha Di Kota Gianyar tahun 2019 Completeness Analysis of Inpatien Ganesha Hospital Medical Records in Gianyar City in 2019,” J. Rekam Medis dan Inf. Kesehat., vol. 2, no. 2, pp. 106–110, 2019, [Online]. Available: http://dx.doi.org/10.31983/jrmik.v2i2.5353.
A. Anwar, “Tanggung Gugat Resiko Dalam Aspek Hukum Kesehatan,” Sasi, vol. 23, no. 2, p. 149, 2018, doi: 10.47268/sasi.v23i2.105.
L. N. Febrianti and I. Sugiarti, “Kelengkapan Pengisian Formulir Laporan Operasi Kasus Bedah Obgyn Sebagai Alat Bukti Hukum,” J. Manaj. Inf. Kesehat. Indones., vol. 7, no. 1, p. 9, 2019, doi: 10.33560/jmiki.v7i1.213.
S. Khofidhoh and M. Hidayati, “Analisis Dokumen Rekam Medis Rawat Inap Kasus Bedah di Rumah Sakit X Bandung,” Cerdika J. Ilm. Indones., vol. 1, no. 10, pp. 1411–1421, 2021, doi: 10.36418/cerdika.v1i10.214.
M. Ulum, “Analisis Kuantitatif Dokumen Rekam Medis Pasien Rawat Inap Kasus Bedah di RSUD Kanjuruhan Kepanjen,” vol. 3, no. 6, pp. 10–18, 2019.
N. Sawondari, G. Alfiansyah, and I. Muflihatin, “Analisis Kuantitatif Kelengkapan Pengisian Resume Medis Di Rumkital Dr. Ramelan Surabaya,” J-REMI J. Rekam Med. Dan Inf. Kesehat., vol. 2, no. 2, pp. 211–220, 2021.
A. Pujilestari, A. Cahyani Daud, F. Lahabila, P. D. Studi, R. Medis dan Informasi Kesehatan, and S. Baktara Gorontalo, “Kelengkapan Pengisian Rekam Medis Pasien Bedah Di Rumah Sakit Umum Daerah Toto Kabila Tahun 2021 Medical Record Completeness of Surgery Patients At Regional Hospital of Toto Kabila 2021,” BAKTARA J. Heal., vol. I, no. I, pp. 1–6, 2021.
D. Kardila and D. Barsasella, “Analisis Kualitatif Dokumen Rekam Medis Kasus Aborsi Tidak Lengkap dalam Aborsi Spontan dengan Metode Hatta Di RSUD Kabupaten Ciamis Tahun 2016,” J. Persada Husada Indones., vol. 5, no. 18, pp. 1–21, 2018, [Online]. Available: http://jurnal.stikesphi.ac.id/index.php/Kesehatan/article/view/212.
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