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All Journal Jurnal Kedokteran Brawijaya
Orin Annahriyah Syukria, Orin Annahriyah
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Medicine & Pharmacology

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Completeness of Medical Record Documents: Exploration of Causes and Solutions Syukria, Orin Annahriyah; Wardhani, Viera
Jurnal Kedokteran Brawijaya Article in Press 2
Publisher : Fakultas Kedokteran Universitas Brawijaya

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Abstract

One of the problems identified at X Hospital in the first six months of 2020 was the delay in returning inpatient medical records to the medical records unit. This study was conducted to explore the elements of the incomplete medical records and the factors that contribute to the emergence of delays in returning these documents. This study uses a qualitative method. Exploration was carried out on 21 medical records using a checklist. Besides, data were obtained through interviews involving the head of the relevant unit and a survey of 52 nurses. Data were collected using interview guidelines and nursing work index-revised (NWI-R) instruments. Incompleteness was found mostly in the patient discharge summary form, initial emergency assessment, and initial inpatient medical assessment. Items that have not been completed at most are officer authentication and information on date and time. One of the root causes of this problem is the factor of the nurse. The results of the NWI-R assessment are 3.15 (maximum value 4), which means that the work environment at X Hospital supports nurses in carrying out their duties well. The highest score is 3.31 on the nurse-doctor relationship factor. The lowest score is 2.93 on adequate human resources to ensure quality services.
Completeness of Medical Record Documents: Exploration on Causes and Solutions Syukria, Orin Annahriyah; Wardhani, Viera
Jurnal Kedokteran Brawijaya Vol. 31 Supplement 2 (2021)
Publisher : Fakultas Kedokteran Universitas Brawijaya

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21776/ub.jkb.2021.031.02.11s

Abstract

The delay in returning inpatients' medical record documents (MRDs) to the medical records subdivision can cause some effects. This study was conducted to explore MRD completeness and the factors causing the delays in returning the document. This study used a descriptive observational method. Exploration was carried out on 21 MRDs using a checklist as an instrument. Besides, data were obtained through interviews involving the heads of related subdivisions and surveys on 52 nurses. Data were collected using an interview guide and a nursing work index-revised (NWI-R) instrument adapted into Indonesian. MRDs returned on time were complete in content and form than documents returned late to the medical records subdivision. One of the root causes of this problem is the officer factor, in this case is the nurse. The result of the NWI-R assessment is 3.15 (a maximum score of 4), meaning that the work environment in X Hospital supports nurses in carrying out their duties well. The highest score, 3.31, is the nurse-doctor relationship factor. The lowest value, 2.93, is the factor of resources adequacy to provide quality services. The possible solutions are to carry out routine briefings related to filling in and returning DRM followed by training.
Co-Authors Viera Wardhani