Year: 2024 | Month: November | Volume: 11 | Issue: 11 | Pages: 263-268
DOI: https://doi.org/10.52403/ijrr.20241121
Review of Completeness of Diagnosis Filling in Medical Record for Inpatients at Mental Hospital. Prof. HB. Saanin Padang
Sayati Mandia1, Nurhasanah Nasution2
1,2Medical record and Health Information Academy (APIKES) IRIS
Corresponding Author: Sayati Mandia
ABSTRACT
Hospitals are health care institutions that provide comprehensive individual health services that provide inpatient, outpatient, and emergency services. To realize this, hospitals need to organize medical record services to support the provision of health services. The important thing that must be considered by medical record personnel in maintaining the quality of medical records is the completeness of medical information related to the patient's medical history starting from the beginning of treatment until discharge from the hospital. The research aim that the results of this study can improve the quality of medical records and hospital accreditation. This research was conducted in June, 2024 at RSJ. Prof. HB. Saanin and continued with data processing at the Academy of Recorders and Health Information IRIS Padang. The type of research used in this study is descriptive research with quantitative methods and direct observation of medical record documents. Population of study was medical record documents for inpatients in in January - March 2024 totaling 600 medical record documents. The sample size using the Slovin formula was 99 samples. Result of research show that highest distribution of diagnoses based on ICD-10 at Prof. Hb Saanin Padang was paranoid schizophrenia with 35 patients, completeness of filling in the main diagnosis and diagnosis code in cases of mental disorders was 96%, Percentage of readability of diagnosis writing, where the writing of the main diagnosis and secondary diagnosis on the medical record is 100%.
Keywords: Completeness, Medical record, diagnose.
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