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ZENODO
Article . 2023
License: CC BY
Data sources: ZENODO
Journal of Health and Medical Sciences
Article . 2023 . Peer-reviewed
Data sources: Crossref
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Analysis of Completeness of Filling in Medical Records in Inpatients of Orthopedic Surgery to Improve Quality Services at Hasan Sadikin Hospital Bandung, Indonesia

Authors: Beni Gunawan; Dodi Syaripudin;

Analysis of Completeness of Filling in Medical Records in Inpatients of Orthopedic Surgery to Improve Quality Services at Hasan Sadikin Hospital Bandung, Indonesia

Abstract

This study aimed to find out how to implement filling out the medical records for orthopedic surgery at Hasan Sadikin General Hospital, Bandung. The research was conducted using a qualitative descriptive method, namely analyzing and describing the data and explaining the results obtained in full on the completeness of the medical record. The results showed that filling out the medical record form was incomplete with a population of 139 Delinquent Medical Record (DMR) samples; 54 DMR were taken. The highest incomplete form in the Authentication Review, namely "Nursing Assessment," there were 12(22%) complete 42(78%) incomplete; the highest incomplete form in the Reporting Review, namely "Medication Notes," there were 13(24%) complete 41(76%) incomplete. Incomplete medical record filling includes (1) The level of understanding of nurses and doctors on the importance of filling out medical records, (2) Doctors' delays and limitations on practice time, (3) Doctors and nurses' busyness levels, (4) Doctors' dependence on nurses, (5) the lack of attention of doctors and nurses towards filling out medical records. Suggestions for assembling officers to be more focused and pay attention to their work so that medical record documents with incomplete contents can be controlled and controlled periodically so that medical record documents are better with lower DMR numbers on filling

Keywords

Hospitalization, Medical records, Service Quality

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selected citations
These citations are derived from selected sources.
This is an alternative to the "Influence" indicator, which also reflects the overall/total impact of an article in the research community at large, based on the underlying citation network (diachronically).
BIP!Citations provided by BIP!
popularity
This indicator reflects the "current" impact/attention (the "hype") of an article in the research community at large, based on the underlying citation network.
BIP!Popularity provided by BIP!
influence
This indicator reflects the overall/total impact of an article in the research community at large, based on the underlying citation network (diachronically).
BIP!Influence provided by BIP!
impulse
This indicator reflects the initial momentum of an article directly after its publication, based on the underlying citation network.
BIP!Impulse provided by BIP!
0
Average
Average
Average
Green