Manghopol Hasiholan Siahaan, Bonthor (2021) ANALISIS KELENGKAPAN DOKUMEN REKAM MEDIS PASIEN TB PARU DI RUANG BOUGENVILE RUMAH SAKIT X KOTA BATAM TRIWULAN IV TAHUN 2020. ["eprint_fieldopt_thesis_type_d3rmk" not defined] thesis, STIKES Awal Bros Batam.
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Abstract
PROGRAM STUDI DIII REKAM MEDIS DAN INFORMASI KESEHATAN STIKES AWAL BROS Karya Tulis Ilmiah (KTI), 2021 Analisis Kelengkapan Dokumen Rekam Medis Pasien Tb Paru Di Ruang Bougenvile Rumah Sakit X Kota Batam Triwulan IV Tahun 2020 Bonthor Mmanghopol Hasiholan Siahaan. 00418006 X + 109 Halaman + 4 Tabel + 4 Lampiran ABSTRAK LATAR BELAKANG: Kelengkapan rekam medis yaitu dilakukannya pengecekan kembali keterisisan pada bagian-bagian isi dari formulir rekam medis dengan maksud menemukan kesalahan atau kekurangan yang berkaitan dengan pendokumentasian rekam medis. Ketidaklengkapan pengisian berkas rekam medis akan mengakibatkan catatan yang termuat bisa menjadi tidak sinkron serta informasi kesehatan pasien terdahulu sulit diidentifikasi. TUJUAN:Mengetahui penyebab ketidaklengkapan pengisisan formulir Assesmen awal medis dan formulir rekonsiliasi obat dalam dokumen rekam medis. METODE: Jenis penelitian yang adalah penelitian kualitatif dengan pendekatan kualitatif yang dilakukan di unit rekam medis untuk melakukan observasi pada formulir Assesmen Awal Medis dan formulir Rekonsiliasi Obat HASIL: Dari hasil penelitian kelengkapan Assesmen Awal Inap Medis tertinggi pada kelengkapan identitas bulan November (84,62%) dan terendah terdapat di laporan yang dibutuhkan (25%) bulan Desember untuk Rekonsiliasi obat kelengkapan identitas tertinggi pada bulan November (41,18%) dan komponen autentifikasi, pelaporan yang dibutuhkan dan teknik pencatatan yang baik kelengkapannya (0%). Setelah dilakukan wawancara didapatkan faktor yang menyebabkan terjadinya ketidaklengkapan sumber daya manusia yang kurang (MAN), SOP yang tidak dijalankan (Method) dan kurang optimalnya pelaksanaan ceklist kelengkapan formulir rekam medis (Material). KESIMPULAN: Ketidaklengkapan formulir rekam medis masih terdapat hambatan dalam unsur sumber daya manusia yang kurang ,SOP yang tidak dijalankan dan kurang optimalnya pelaksanaan ceklist kelengkapan formulir rekam medis . Kata kunci : Kelengkapan, Rekam Medis, Rawat Inap STUDY PROGRAM DIPLOMA ON MEDICAL RECORD AND HEALTH INFORMATION STIKES AWAL BROS Scientific Writing, 2021 Analysis on the Completion of Medical Record Documents for Pulmonary Tuberculosis Patients in Bougenvile Room Hospital X Batam City Fourth Quarter 2020 Bonthor Mmanghopol Hasiholan Siahaan. 00418006 X + 109 Pages + 4 Tables + 4 Attachments ABSTRACT BACKGROUND: The completion of medical records is the process of verificating the contents of the medical record form with the intention of finding errors or deficiencies related to the documentation of medical records. The incompletion of the medical record form will result in additional information being out of sync and making the identification of the patient's previous health information more difficult. OBJECTIVE: To find out the cause of the incomplete data of the initial medical assessment form and the drug reconciliation form in the medical record document. METHOD: This type of research is a qualitative research with a qualitative approach which is carried out in the medical record unit to observe the Initial Medical Assessment form and Drug Reconciliation form. RESULTS: From the results of the research on the completion of the Initial Medical Inpatient Assessment, the highest completion of patient's data was in November (84.62%) and the lowest was in the report required (25%) in December for drug reconciliation, the highest completion of patient's data was in November (41.18%) and the components of authentication, required reporting and good recording techniques are complete (0%). After the interview, it was found that the factors that caused the incomplete data are the lack of human resources (MAN), the SOP was not implemented (Method) and the optimal implementation of the checklist for the completion of the medical record form (Material) was not achieved yet. CONCLUSION: Incomplete medical record forms still have obstacles in the element of the lack of human resources, SOP that are not implemented, and the implementation of the checklist for the completion of medical record forms is not optimal. Keywords: Completion, Medical Records, Hospitalization
| Item Type: | Thesis (["eprint_fieldopt_thesis_type_d3rmk" not defined]) |
|---|---|
| Subjects: | D3 Rekam Medis D3 Rekam Medis > Layanan Rekam Medis |
| Divisions: | D3 Rekam Medis |
| Depositing User: | lib. psdku. univawalbros |
| Date Deposited: | 13 Dec 2021 02:07 |
| Last Modified: | 16 Feb 2022 04:44 |
| URI: | http://repositori.psdku.univawalbros.ac.id/id/eprint/113 |
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