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All Journal Open Access Indonesian Journal of Medical Reviews Student Scientific Creativity Journal
Wiwik Viatiningsih
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Arts Decision Sciences, Operations Research & Management Economics, Econometrics & Finance Education Health Professions Languange, Linguistic, Communication & Media Medicine & Pharmacology Social Sciences

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Tinjauan Kelengkapan Pengisian Formulir Ringkasan Pasien Pulang Rawat Inap Pada Kasus Covid-19 di Rsud Tarakan Jakarta Tahun 2022 Izmi Novianita; Wiwik Viatiningsih; Nanda Aula Rumana; Puteri Fannya
Student Scientific Creativity Journal Vol. 1 No. 4 (2023): Juli : Student Scientific Creativity Journal
Publisher : Pusat Riset dan Inovasi Nasional

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55606/sscj-amik.v1i4.1547

Abstract

Medical records are an important part of reporting and recording as well as assisting the implementation of service delivery to patients, one of which is a summary form for discharge patients, which includes all services that have been provided to patients. It was found that there were still medical records that were not 100% complete according to service quality standards at the Tarakan Hospital, Jakarta. Researchers analyzed the medical records of inpatients for COVID-19 cases, especially the summary form for discharge patients. This study uses a descriptive method with a quantitative analysis approach. The purpose of this study was to determine standard operating procedures and calculate the percentage of completeness of inpatient medical records on the summary form of inpatient discharge patients in the case of covid-19 in March 2022, and to find out the obstacles in filling out the summary form of inpatient discharge in cases of covid-19 . Based on the results of a study of 152 medical records of hospitalized patients with COVID-19 cases, the average completeness rate was 92% complete and 8% incomplete. The need to resocialize standard operating procedures for filling out medical records and the need for hospital director decisions regarding the discipline of filling out medical records should be able to be carried out properly and on time .
Overview of Completeness of Filling Out Inpatient Discharge Summary Form at General Ahmad Yani General Hospital Metro in 2021 Aulia, Ni Wayan Riskita; Wiwik Viatiningsih; Nanda Aula Rumana; Puteri Fannya
Open Access Indonesian Journal of Medical Reviews Vol. 2 No. 2 (2022): Open Access Indonesian Journal of Medical Reviews
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/oaijmr.v2i2.179

Abstract

Medical records are the property of hospitals that must be maintained because they are useful for patients, doctors, and hospitals. Medical record documents are very important in carrying out the quality of medical services provided by hospitals and their medical as well as accurate evidence in court, doctors, nurses, and other health workers who treat patients are required to complete medical records following applicable regulations. This study aims to describe the completeness of filling out inpatient discharge summary form at General Ahmad Yani Hospital Metro in 2021. This study used a descriptive research method. The research location is the Medical Record Unit of General Ahmad Yani General Hospital Metro Lampung. This research was conducted in October 2021. Of the 100 samples of medical records, the completeness of the inpatient discharge summary form was completed. There are 80% complete and 20% incomplete, where the completeness value of 100% is found in the patient identity filling item, and there are no scribbles. Meanwhile, 20% incompleteness is found in important note items (5%) and authentication (15%). In conclusion, standard operating procedures for completeness of medical records already exist and the implementation of completeness of medical record files has been carried out according to applicable standards, but it can be seen that the steps in the SOP are not detailed and less thorough.
Overview of the Implementation of Medical Record Maintenance at Tarakan Hospital Jakarta in 2021: A Qualitative Study Noviliana, Tiara; Siswati; Puteri Fannya; Wiwik Viatiningsih
Open Access Indonesian Journal of Medical Reviews Vol. 2 No. 2 (2022): Open Access Indonesian Journal of Medical Reviews
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/oaijmr.v2i2.181

Abstract

A medical record is a file that contains notes and documents about patient identity, examination, treatment, actions, and other services that have been provided to patients. Medical records in carrying out maintenance and protection so that medical records are protected from damage and can facilitate the service process. This study discusses the process or activities of maintaining medical records at the Tarakan Hospital, Jakarta. The purpose of this study was to find out what factors could trigger the occurrence of damage or dangers to the medical record unit and to find out the preventive actions taken by the hospital in protecting medical records. This type of research uses a qualitative descriptive method, which describes the implementation of the maintenance of medical record files in the filing room in 2021. The implementation of medical record maintenance by medical record unit officers, it does not follow the SOP that has been set by Tarakan Hospital Jakarta. Constraints in maintaining medical records are seen from biological, chemical, environmental, and security factors. These obstacles are often the factors that cause damage to medical records such as dust, fire/coal on cigarettes, pests/insects, and chemical liquids and maintenance of medical records at the Tarakan Hospital.
Co-Authors Aulia, Ni Wayan Riskita Izmi Novianita Noviliana, Tiara Puteri Fannya Siswati