Triono, Galuh Aryasti (2022) TINJAUAN FAKTOR PENYEBAB KETIDAKLENGKAPAN PENGISIAN BERKAS REKAM MEDIS RAWAT JALAN DI PUSKESMAS SEI PANCUR BATAM. D3 Rekam Medis dan Informasi Kesehatan thesis, Universitas Awal Bros.
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Abstract
PROGRAM STUDI D-III REKAM MEDIS DAN INFORMASI KESEHATAN UNIVERSITAS AWAL BROS Karya Tulis Ilmiah (KTI), 2022 TINJAUAN FAKTOR PENYEBAB KETIDAKLENGKAPAN PENGISIAN BERKAS REKAM MEDIS RAWAT JALAN DI PUSKESMAS SEI PANCUR BATAM Galuh Aryasti Triono, 00419017 X + 67 Halaman + 4 Tabel + 1 Kerangka + 3 Gambar + 12 Lampiran ABSTRAK Latar Belakang : Dalam pelayanan medis Puskesmas, dokumen rekam medis sangatlah penting karena dapat dijadikan sebagai bukti atas perawatan medis yang diberikan kepada pasien. Berdasarkan hasil observasi awal penelitian masih banyak ditemukannya berkas rekam medis yang tidak terisi dengan lengkap bahkan double berkas rekam medis akibat tidak adanya ceklis kelengkapan pengisian berkas rekam medis dan tidak adanya laporan berkas rekam medis yang dipinjam atau dikembalikan. Tujuan : Mengetahui faktor penyebab ketidaklengkapan pengisian berkas rekam medis rawat jalan berdasarkan man, material, method, machine di Puskesmas Sei Pancur. Metode : Metode penelitian yang dipakai di penelitian in memakai metode kualitatif dengan melakukan observasi dan wawancara di Puskesmas Sei Pancur. Hasil : Berdasarkan hasil wawancara yang telah diakukan faktor ketidaklengkapan pengisian berkas rekam medis rawat jalan disebabkan oleh tidak pernah dilakukannya pelatihan kepada petugas rekam medis dan dokter, belum terlaksananya SOP dengan baik, tidak adanya buku ceklis kelengkapan berkas rekam medis. Kesimpulan : Sumber daya manusia, alat, SOP dan fasilitas mempengaruhi dalam kelengkapan berkas rekam medis rawat jalan di Puskesmas Sei Pancur oleh karena itu diperluannya evaluasi terkait banyaknya kekosongan pada beberapa kolom rekam medis pasien rawat jalan. Kata Kunci : Ketidaklengkapan; Rekam Medis; Rawat Jalan; Puskesmas Kepustakaan : 3 Buku (2016-2020) + 12 Jurnal (2007-2020) PROGRAM STUDI D-III REKAM MEDIS DAN INFORMASI KESEHATAN UNIVERSITAS AWAL BROS Karya Tulis Ilmiah (KTI), 2022 REVIEW OF THE CAUSES OF INCOMPLETE COMPLETION OF OUTCOME MEDICAL RECORD FILES AT SEI PANCUR HEALTH CENTER BATAM Galuh Aryasti Triono, 00419017 X + 67 Pages + 4 Tables + 1 Outline + 3 Pictures + 12 Attachments ABSTRACT Background: In Puskesmas medical services, medical record documents are very important because they can be used as evidence of medical care provided to patients. Based on the results of the initial observations of the study, there were still many medical record files that were not filled out completely and even double medical record files due to the absence of a checklist for the completeness of filling out medical record files and the absence of reports of borrowed or returned medical record files. Objective: Knowing the factors causing the incomplete filling of outpatient medical record files based on man, material, method, machine at the Sei Pancur Health Center. Methods: The research method used in this study uses a qualitative method by conducting observations and interviews at the Sei Pancur Health Center. Result : Based on the results of interviews that have been carried out, the incompleteness of filling out outpatient medical record files is caused by never having training for medical record officers and doctors, not implementing SOPs properly, and not having a checklist for completeness of medical record files. Conclusion: Human resources, tools, SOP and facilities affect the completeness of the outpatient medical record file at the Sei Pancur Health Center, therefore it is necessary to evaluate the number of vacancies in several outpatient medical record columns. Keywords: Incompleteness; Medical Records; Outpatient; Public Health Center Literature : 3 Books (2016-2020) + 12 Journals (2007-2020)
| Item Type: | Thesis (D3 Rekam Medis dan Informasi Kesehatan) |
|---|---|
| Subjects: | D3 Rekam Medis > Layanan Rekam Medis |
| Divisions: | D3 Rekam Medis |
| Depositing User: | Galuh Aryasti |
| Date Deposited: | 23 Feb 2023 06:21 |
| Last Modified: | 23 Feb 2023 06:21 |
| URI: | http://repositori.psdku.univawalbros.ac.id/id/eprint/205 |
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