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Wahyu Ratri Sukmaningsih
Politeknik Indonusa Surakarta
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Journal : Science Midwifery

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Analysis of completeness factors for filling inpatient discharge summaries H. Hanafie regional hospital Muara Bungo Jambi 2024 Astrianda, Veita; Sukmaningsih, Wahyu Ratri
Science Midwifery Vol 13 No 2 (2025): June: Health Sciences and related fields
Publisher : Institute of Computer Science (IOCS)

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.35335/midwifery.v13i2.1953

Abstract

Although the discharge summary is essential for ensuring continuity of patient care, supporting clinical decision-making, and enabling administrative processes such as BPJS insurance claims, RSUD H. Hanafie Muara Bungo continues to face challenges in achieving complete and standardized medical documentation. This study analyzes the factors influencing the completeness of inpatient medical resumes at RSUD H. Hanafie using the 5M framework: Man, Method, Machine, Material, and Money. A qualitative descriptive approach was employed, with data collected through document review, observation, and interviews with Responsible Doctors (DPJP) and the Head of the Medical Records Installation. A total of 100 medical resumes were selected using simple random sampling, based on the Slovin formula with a 10% margin of error. Data were analyzed through data reduction, presentation, conclusion drawing, and validation using triangulation. Results showed that the patient identification component achieved 100% completeness, while important reporting, authentication, and recording reached 98%, 95%, and 77%, respectively. Key influencing factors included limited routine training and discipline (Man), absence of SOPs and weak monitoring (Method), suboptimal form design (Material), insufficient devices and system disruptions (Machine), and budget constraints (Money). To address these issues, a comprehensive strategy involving health worker collaboration, system support, and strong management commitment is essential to ensure that the clinical, legal, and administrative functions of medical resumes are fulfilled.
Co-Authors Agus Ahmad Arifin AGUSTI DEKY MAHENDRA PUTRA Agustyarum Pradiska Budi Ahmad Sunandar Ahmad Sunandar Aisyah Zakiyah Darojat Anita Marsyahada Apoina Kartini Aprilia Trisiya Dewi Aries Widiyoko Arifin, Agus Ahmad Arisna, Arisna Aryawan Eka Syahputra Astrianda, Veita Awali'ah, Salsabilla Isro'atul Aztiza, Zahra Anggra Darmawan, Septa Aulia Deby Davista Dessy Lucia Irawati Devia Eka Permatasari, Devia Elisabrina, Diyah Faisal, Muhamad Zidan FATIMAH, Lina Nur Fauziah Kurnia Permatasari Fauziah, Nurlita Habibi, Musta'inul Handoko, Anggraini Luthfiyyah Syarry Hanifah, Mutiara Nur Husna Sarirah Husin Husna Sarirah Husin Iswari Septiana Nindi Wulandari Iswari Septiana Nindi Wulandari Kurniasari, septiana Vivi Kurniawan, Adhitya Wahyu Kusumawati, Pingki Dwi Licia, Rizka Lina Nur FATIMAH Maria Ervina Damaranti Mathar, Irmawati Muhadzib, Naufal Mukaromah, Maulina Munawwarah Munawwarah, Munawwarah Mutiara Nur Hanifah Nadilla Putri Melisa Nadilla Putri Melisa Novia Novratilova, Sinta Permatasari, Fauziah Kurnia Perwirani, Resia Pingki Dwi Kusumawati Pitaloka, Dyah Ayu Prayoga, Dina Ayu Putri, Wella Niki Rafinda Sinta Sani Ratna Sabilla - Regina Putri, Frestiany Resia Perwirani Resia Perwirani Rizka Licia Rizka Licia Rohmiyati, Sri Salsabilla Isro'atul Awali'ah Saputro, Bayu Ageng Setyawati, Zakiya Murni Shavitri Chandriani Sri Achadi Nugraheni Sri Suparti SRI WULANDARI Sri Wulandari Wahyu Wijaya Widiyanto, M.Kom Wibowo, Lucky Nurcahya Widiyanto, Wahyu Wijaya Wulandari, Novita Sri Zahra Zahra