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Completeness of filling medical record documents on inpatient ward, Ungaran General Hospital-Semarang, Central Java -Indonesia

Authors: Lestari Wiji; Astuti Retno; Isworo Slamet;

Completeness of filling medical record documents on inpatient ward, Ungaran General Hospital-Semarang, Central Java -Indonesia

Abstract

Ungaran Hospital is a type C referral hospital in Semarang regency, therefore it must have excellent and good service, including services for patients and patient’s regularity medical records. The mechanism for filling out medical record documents is often a barrier to services which results in a delayed return of medical record documents. This study aims to determine the effectiveness of filling medical record documents in 8 wards, in January - February 2020. The purpose of this study: This study aims to determine the incompleteness of filling medical record documents which result in delays in submitting medical record documents to the assembly unit. This research was conducted from February to March 2020, with the type of descriptive research that is interviews and observations of medical records officers. The results of the study were based on the calculation of 30 medical record documents consisting of 15 inpatient medical record documents and 15 outpatient medical record documents, the checklist table used to determine the completeness of filling medical record documents. Based on the analysis of medical record documents on hospitalization which includes a review of identification, reporting, authentication, and recording of 30 medical record documents studied there were 28 complete medical record documents and 2 incomplete medical records. It is necessary to provide guidance to doctors/nurses considering the importance of completeness of the contents of medical record documents in accordance with the conditions or needs of patients.

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Keywords

Quantitative analysis; Assembling; Medical record documents; Services; Returning documents

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selected citations
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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).
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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!
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