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All Journal Indonesian Journal of Health Information Management (IJHIM)
Syamsuddin
STIKES Panakkukang
Health Professions Public Health

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Tinjauan Kelengkapan Pengisian Formulir Ringkasan Masuk & Keluar Pada Kasus Pasien Penyakit Dalam Rumah Sakit Bhayangkara Makassar Putri Amalia; Syamsuddin; Mikawati; Nurintan Malik
Indonesian Journal of Health Information Management Vol. 6 No. 1 (2026)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v6i1.214

Abstract

Abstract Backround: The completeness of the entry and exit summary form is very important because it has a function as a source of information about the course of the disease, indexing the disease and as a source of information in preparing hospital reports. As explained in the Hospital SPM, the completeness of medical records, especially the entry & exit summary form, must be filled in at least 100%. Objective: To find out the completeness of filling out the entry & exit summary form in the case of internal medicine patients at Bhayangkara Makassar Hospital. Method: This study uses a descriptive method with a quantitative approach, a total sample of 57 medical records with sample withdrawal using the slovin formula. Data collection with observation and interviews was then processed using the IBM SPSS 23 application. Results: The results of the study were complete patient identification review (95%), incomplete (5%), complete important reporting review (63%), incomplete (37%), complete authentication review (91%), incomplete (9%), complete and correct documentation review (98%), incomplete (2%). Conclusion: The completeness of filling out the summary form for entering and exiting Bhayangkara Hospital Makassar is still incomplete. It is hoped that regular socialization and evaluation will be held as well as rewards and punishments will be given to officers involved in filling in medical records.
Tinjauan Keterlambatan Pengembalian Berkas Rekam Medis Pasien Rawat Jalan Di RSUD Haji Kota Makassar Hilwa Alfausia; Syamsuddin; Mikawati; Narfandy
Indonesian Journal of Health Information Management Vol. 6 No. 1 (2026)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v6i1.216

Abstract

Latar belakang : Pengembalian berkas rekam medis pasien rawat jalan harus dikembalikan sesuai standar prosedur operasional yaitu 1x24 jam untuk rawat jalan. Keterlambatan pengembalian berkas rekam medis dapat mempengaruhi pelayanan rekam medis dan akan menghambat kegiatan selanjutnya, seperti assembling, koding, analisis, dan indexing. Tujuan : Diketahui karakteristik berkas rekam medis pasien rawat jalan yang dikembalikan tepat waktu dan jumlah berkas rekam medis yang dikembalikan tidak tepat waktu . Metodologi : Penelitian ini menggunakan metode deskriptif dengan pendekatan kuantitatif. Sampel penelitian ini adalah dengan menggunakan lembar observasi dengan total 80 sampel pada bulan juni tahun 2024. Hasil : Dari 80 berkas rekam medis yang diteliti terdapat 50 berkas yang dikembalikan tidak tepat waktu dan 30 berkas rekam medis yang dikembalikan tepat waktu. Kesimpulan : Ketidaktepatan pengembalian berkas rekam medis pasien rawat jalan bulan juni tahun 2024 sebanyak 62.5% atau 50 berkas dari total sampel 80 berkas, sedangkan yang dikembalikan tepat waktu sebanyak 37.5% atau 30 berkas rekam medis.
Co-Authors Hilwa Alfausia Mikawati Narfandy Nurintan Malik Putri Amalia