a Analisis Kelengkapan Pengisian Berkas Rekam Medis Rawat Jalan Di Puskesmas Pleret

Abstract

Filling out outpatient medical record files is an important part of health information management. The existence of complete and accurate medical record files is necessary to ensure continuity of patient care, clinical evaluation, as well as legal and administrative interests. This study aims to analyse the completeness of filling out medical record files in hospitals in certain areas by considering the factors that cause incompleteness.

This type of research uses descriptive methods with a qualitative approach, the design used is a cross sectional survey. The subjects in this study were the head of medical records, general nurses, general practitioners, nurses, dentists, and medical records officers. The object in this study was the patient's medical record file. Data were obtained through observation, interview, and documentation study.

Analysis of the completeness of filling in medical record files at Puskesmas Pleret from 100 samples of medical record files in filling in patient identity data reached 95% completeness which was incomplete 5%, complete date and time 45% incomplete 55%, complete history results 92% incomplete 8%, physical examination results and medical support complete 90% incomplete 10%, name and signature of the doctor complete 64% incomplete 36%.... Factors causing incomplete filling of medical record files at the Pleret Health Centre in terms of human factors are due to lack of accuracy in filling, the large number of patients who perform services so that medical record files forget to be filled in and also time constraints.