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Muhlizardy Muhlizardy
Universitas 'Aisyiyah Surakarta
Religion Agriculture, Biological Sciences & Forestry Arts Humanities Computer Science & IT Decision Sciences, Operations Research & Management Dentistry Economics, Econometrics & Finance Education Electrical & Electronics Engineering Engineering Health Professions Languange, Linguistic, Communication & Media Law, Crime, Criminology & Criminal Justice Medicine & Pharmacology Nursing Public Health Social Sciences Veterinary Other

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Journal : Jurnal Rekam Medik

 1 
Analisis Kelengkapan Berkas Rekam Medis Elektronik Pada Pasien Covid-19 Di Rumah Sakit Muhlizardy Muhlizardy; Winda Azmi Meisari
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 1 (2022): April
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (167.753 KB) | DOI: 10.47134/rmik.v1i1.10

Abstract

The medical record as a record of the patient's illness is a file that must be filled in completely. The incomplete filling of the medical record file will result in the notes contained being out of sync and difficult to identify the previous patient's health information. Therefore, the completeness of filling out the medical record file must reach 100% for 1x24 hours after the patient leaves the hospital. This study aims to determine the level of completeness of filling out electronic medical records in Covid-19 patients at PKU Muhammadiyah Gamping Hospital. The design of this research is descriptive quantitative. The sample in this study was the medical record file for Covid-19 patients in a period of one month as many as 155 medical records. The method of data collection is in the form of a checklist. The results showed that 100% of the electronic medical record files were incomplete. The most complete indicators are the results of supporting the diagnosis (100%), nursing actions (98.9), and pain assessment (93.5%).
Co-Authors Adelia Cahya Utami Annisa Permatasari, Anggie Ardhani, Rahmad Asani, Fitrianti Asti Nurhayati Aulia, Salma Nur Dyah Rochani Husnaa Dian Puspita Husnaa Dian Puspita Ilham Karin Rizkiawan Isnaini, Latifah Ita Permatahati Layli Nur A Meila Nissa Solihah Meila Nissa Solihah Meisari, Winda Azmi Meylia Isna Nabilla Tri Pramita Utami Nannyk Widyaningrum Nisa Nur Rahma Nur Istiqomah, Nadya Primanda Budi Utami Putri, Anggun Dhipa Rahmad Ardhani Retno Tri Utami Tafdilla Rahmawati Tri Utami, Retno Ummu Muti’ah Viviana Rahmawati Wahyu Miranti Winda Azmi Meisari Winda Azmi Meisari Yunuarti Yunuarti Zahrani, Nafisa