Tugas Akhir DIII
Tinjauan Kelengkapan Pengisian Rekam Medis Kasus Bedah di Rumah Sakit Roemani Muhammadiyah Semarang
- Bagikan:
A complete medical record describes all the services that is provided to the patient, and can be used in quality of services evaluation. Results of medical record completeness in Rumah Sakit Roemani Muhammadiyah Semarang in October and November is 54,05%. It has not reached the SPM which have been decided in Kepmenkes Nomor 129 tahun 2008 about Standar Pelayanan Minimal Rumah Sakit is 100%. This reseach aims to knowing the completeness of medical record of surgical cases and factors causing incomplete medical record in Rumah Sakit Roemani Muhammadiyah Semarang.
The kind of researched is descriptive with using instrument checklist and interview guidelines. The research samples are 92 medical records and 17 medical record officers. The sampling technique is simple random sampling.
The result showing of completeness of patient identification review 99% filled and 1% unfilled. The important report review 87% filled and 13% unfilled. The authentication review 75% filled and 25% unfilled. The recording review 95% good recording and 5% not good recording. Incomplete medical record caused by medical record officer that not graduated from DIII RMIK. Officers have not received any training about medical record completeness. Lack of cooperation of officers that is involved to fill medical records and there are nothing medical record control cards. The author’s suggestion, giving the doctors and nurses to provide authentication and recording that corresponds to the rule.
Informasi Detail
| Pernyataan Tanggungjawab |
Adhani Windari, SKM, M.Kes
|
|---|---|
| Pengarang |
Elli Tiya Maysaroh - Pengarang Utama
|
| NIM |
P1337437115040
|
| Bahasa |
Indonesia
|
| Deskripsi Fisik |
XV + 76 hlm.; Bibl.; ilus.; 29 cm
|
| Dilihat sebanyak |
756
|
| Penerbit | Prodi DIII Rekam Medis dan Informasi Kesehatan Semarang POLTEKKES KEMENKES SEMARANG : POLTEKKES KEMENKES SEMARANG., 2018 |
|---|---|
| Edisi | |
| Subjek | |
| Klasifikasi |
081
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