Factors of Incomplete Inpatient Medical Records Filling at Dr. H. Slamet Martodirdjo Regional General Hospital Pamekasan

Authors

  • Achmad Fajar Master Program in Hospital Management Faculty of Medicine Universitas Brawijaya Malang
  • Holipah Holipah Department of Public Health Sciences Preventive Medicine Faculty of Medicine Universitas Brawijaya Malang
  • Ike Handayani Dr. H. Slamet Martodirdjo General Hospital Pamekasan

DOI:

https://doi.org/10.21776/ub.jkb.2024.033.01.4s

Keywords:

Hospital, incomplete, medical records

Abstract

Hospitals have an important role in improving health status by providing quality services, including complete medical record data and information. Complete and accurate medical records can be used for health care and patient treatment, evidence in law enforcement, medical discipline and medical ethics, educational and research purposes, basis of payment for health care costs, and health statistical data. This study aimed to identify the factors causing the incomplete filling of inpatient medical records at Dr. H. Slamet Martodirdjo Regional General Hospital Pamekasan. This research applied the descriptive observational method, with data collected through secondary data analysis using document studies and problem exploration using focus group discussions (FGD). The document study was conducted on 80 samples of inpatient medical records, while the FGD was conducted by inviting the head of the planning department, medical records officer, and 8 heads of inpatient wards to find out the causes and solutions for incomplete medical record files. The study results found that the number of incomplete medical records was 76.25%, with the highest percentage of incompleteness due to doctors, pharmacists, and nurses. The main problem causing the incompleteness of medical records was professional caregivers (PPA) who lacked discipline. The solutions obtained were management meetings and evaluations to professional caregivers, constructing policies that regulate reward and punishment systems, monitoring the checklists of medical record completeness, and routine evaluation of medical record files.

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References

Wirajaya MK and Nuraini N. Faktor-faktor yang Mempengaruhi Ketidaklengkapan Rekam Medis Pasien pada Rumah Sakit di Indonesia. Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI). 2019; 7(2): 158-165.

Faida EW. Manajemen Sumber Daya Manusia dan Ergonomi Unit Kerja Rekam Medis. Sidoarjo: Indomedia Pustaka; 2019.

Ratman D. Aspek Hukum Informed Consent dan Rekam Medis dalam Transaksi Terapeutik. Bandung: Keni Media; 2013.

Winarti SS. Analisis Kelengkapan Pengisian dan Pengembalian Rekam Medis Rawat Inap Rumah Sakit. Jurnal Administrasi Kesehatan Indonesia. 2013; 1(4): 345–351.

Kementerian Kesehatan Republik Indonesia. Peraturan Menteri Kesehatan Republik Indonesia Nomor 269/MENKES/PER/III/2008 tentang Rekam Medis. Jakarta: Kemenkes RI; 2008.

Mawarni D and Wulandari RD. Identifikasi Ketidaklengkapan Rekam Medis Pasien Rawat Inap Rumah Sakit Muhammadiyah Lamongan. Jurnal Administrasi Kesehatan Indonesia. 2013; 1(2): 192–199.

Kementerian Kesehatan Republik Indonesia. Menteri Kesehatan Republik Indonesia Nomor 129/MENKES/SK/II/2008 tentang Standar Pelayanan Minimal Rumah Sakit. Jakarta: Kemenkes RI; 2008.

Yuniarto HA, Akbari AD, and Masruroh NA. Perbaikan Pada Fishbone Diagram Sebagai Root Cause Analysis Tool. Jurnal Teknik Industri. 2013; 3(3): 217-224.

Nurhaidah N, Harijanto T, and Djauhari T. Faktor-faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Rawat Inap di Rumah Sakit Universitas Muhammadiyah Malang. Jurnal Kedokteran Brawijaya. 2016; 29(3): 258–264.

Hasanah K, Andrajati R, and Supardi S. Kontribusi Kelengkapan Pengisian Formulir Rekonsiliasi Obat terhadap Penggunaan Obat Rasional pada Pasien Rawat Inap di RSU X Bekasi. Jurnal Kefarmasian Indonesia. 2020; 10(1): 11–18.

Dermawan ARI and Siswati. Gambaran Implementasi Review Rekam Medis Terbuka Dan Review Rekam Medis Tertutup Sesuai SNARS Di Rumah Sakit Husada. Prosiding 4 SENWODIPA 2020, 7 November 2020; p. 10-19.

Susanti IR, Hamzah A, Anggraeni SA, and Widyaningrum K. “ABED TANGI” as a Solution for Time Inaccuracy in Returning Medical Record at X Hospital. Jurnal Medicoeticolegal dan Manajemen Rumah Sakit. 2018; 7(1): 13–21.

Rahmatiqa C, Sulrieni IN, and Sary AN. Kelengkapan Berkas Rekam Medis dan Klaim BPJS di RSUD M. Zein Painan. Jurnal Kesehatan Medika Saintika. 2021; 11(1): 11–15.

Ningsih WF. Kelengkapan Pengisian Resume Medis di Rumah Sakit Khusus Ibu dan Anak (RSKIA) PKU Muhammadiyah Kotagede Yogyakarta. [Scientific Papers]. Sekolah Tinggi Ilmu Kesehatan Jenderal Achmad Yani, Yogyakarta. 2017.

Indar I, Indar I, and Naiem MF. Faktor yang Berhubungan dengan Kelengkapan Rekam Medis di RSUD H. Padjonga Dg. Ngalle Takalar. Jurnal Administrasi dan Kebijakan Kesehatan Indonesia. 2013; 2(2): 10-18.

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Published

2024-05-21

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