Tugas Akhir DIII
Studi Deskriptif Kelengkapan Pengisian Resume Medis Rawat Inap di Rumah Sakit Roemani Muhammadiyah Semarang
- Bagikan:
Medical resume is summary all of treatment the patient and one of the instruments scoring in accreditation the hospital version of 2012. The standard of APK.3.2.1 stating the resume of the patient back home must be complete. Permenkes 129/2008 about standard of minimal service of hospital stating the medical resume complete if the completeness of the filling 100%. The result early study in Roemani Muhammadiyah Hospital Semarang 100% incomplete. The groove assembling activities in the hospital did not check the completeness of filling document medical record. That is possible the document of medical record which stored to the filling become a document incomplete. The purpose of the research is to analyze the completeness of filling.
The type of research is quantitative descriptive. The population of the research is medical resume in the medical record document inpatient 2015 in the filling. The sampling technique is random sampling. Total samples calculated using slovin formula with the mistakes 10%, obtained 100 samples. A method of collecting data is observation using checklist.
The result of research indicates that the most identity of the patient filled incomplete (92%). The most items which filled incomplete is the name of the patient. The review of the important report not filled completely (100%). The most of the item that incomplete is the result of roentgen (examination of Rontgen), followed by a physical inspection and final diagnosis. The most of the review of authentication is filled incompletely (58%) the item that most incomplete is the name of the doctor responsible for the patient. A review the correct documentation overall item did not fill completely (100%). The suggestion of the writer, the correction of the plot of assembling service and do improvement in everystep that should be done but not done.
Informasi Detail
| Pernyataan Tanggungjawab |
Edy Susanto, Lina Umboro Styowati
|
|---|---|
| Pengarang |
Kurnia Putri Apria Ningrum - Pengarang Tambahan
|
| NIM |
P17437113007
|
| Bahasa |
Indonesia
|
| Deskripsi Fisik |
xiv+67 page+28 cm
|
| Dilihat sebanyak |
782
|
| Penerbit | Prodi DIII Rekam Medis dan Informasi Kesehatan Semarang POLTEKKES KEMENKES SEMARANG : Semarang., 2016 |
|---|---|
| Edisi |
2016
|
| Subjek | |
| Klasifikasi |
081
|