Year: 2024 | Month: November | Volume: 11 | Issue: 11 | Pages: 89-94
DOI: https://doi.org/10.52403/ijrr.20241111
Analysis of the Completeness of Medical Records in RSJ. Prof. Dr. Saanin Padang
Nurhasanah Nasution1, Sayati Mandia2
Akademi Perekam dan Informasi Kesehatan (APIKES) IRIS
Corresponding Author: Nurhasanah Nasution
ABSTRACT
Complete medical records are very useful for knowing in detail the patient's history, examinations that have been carried out, and planning further actions. To achieve this, the medical records department is obliged to carry out quality monitoring by carrying out quantitative, qualitative, and statistical analysis. To know whether a medical record file is complete or incomplete, it is necessary to carry out a quantitative analysis, namely four reviews consisting of an identity review, recording review, reporting review, and authentication review. Based on the results of a preliminary study with existing medical record officers, it was stated that every patient's medical record file received from inpatient care was always assessed for completeness but was still not optimal, and incomplete values were always obtained. One of the problems, among others, is in terms of input, namely the high workload of medical record officers, facilities, and infrastructure, especially storage space and technology, which are not yet optimal. It is important to discuss this problem so that researchers research to find out the completeness of medical record files in RSJ. Prof. HB. Saanin Padang City. This research was carried out in March 2024 at RSJ. Prof. HB. Sa'anin Padang. From the study, it was found that the highest percentage of completeness in filling out identification components was the name item at 97.98%, the highest percentage of completeness in important report components was found in the discharge summary form, CPPT and General consent each at 100%, the percentage of completeness in the recording method component was highest in You can use item type x at 100%. In the medical record file, no type-x was used. There is a need for policies regarding filling rules and periodic audits regarding the completeness of medical record files.
Keywords: Completeness, Medical record, files, hospital, analysis.
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