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All Journal Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)
Kusnadi, Fery
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Health Professions Public Health

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Tinjauan Kelengkapan Pengisian Lembar Ringkasan Pulang Resume Pasien Rawat Inap Di Rs Permata Cibubur Kusnadi, Fery; Setiatin, Sali
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 10 No. 2 (2025): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v10i2.1957

Abstract

Quality medical documentation is the foundation of the healthcare system with a direct impact on continuity of care and clinical accountability. The medical resume as an integral component of the medical record serves as a holistic synthesis of therapeutic modalities during hospitalization. This investigation analyzes the completeness of the completion of medical resume documentation through a four-dimensional evaluation: identification modules, clinical reportage segments, authentication elements, and documentation aspects according to standards. This methodology applies a descriptive quantitative paradigm with a cross-sectional survey design on 60 samples of inpatient medical resume documents at Permata Cibubur Hospital during June 2025 using Simple Random Sampling. The research instrument consists of a structured checklist for systematic evaluation through direct observation of the medical resume form. The results of the analysis showed variations in the level of completeness: identification components 95% (5% deficiencies), critical report segments 88.87% (11.13% incomplete), authentication 92.22% (7.78% incompleteness), and proper documentation 93.4% (6.6% incompleteness). The findings show that although the majority of components meet good documentation standards, significant gaps still exist that require systematic optimization. Strategic implications for institutional management include the implementation of a continuous monitoring system and a structured training program for medical personnel to achieve 100% standards in accordance with the Regulation of the Minister of Health Number 24 of 2022.
Co-Authors Sali Setiatin