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Dewi Suciana
Akademi Administrasi Rumah Sakit Mataram
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ANALISIS KUANTITATIF KELENGKAPAN DOKUMEN REKAM MEDIS PASIEN RAWAT JALAN DI PUSKESMAS CAKRANEGARA TAHUN 2021 Januari Lesmana; Dewi Suciana
Nusadaya Journal of Multidiciplinary Studies Vol. 1 No. 1 (2022): Nusadaya Journal of Multidiciplinary Studies, July 2022
Publisher : LPPM, Akademi Administrasi Rumah Sakit Mataram

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.662944/njms.v1i1.7

Abstract

Cakranegara Health Center is one of the health centers in Mataram city. This health center serves both outpatients and inpatients. Every health care institution must have a medical record document. Medical record is a file that contains records and documents about patient identity, examination, treatment, actions and other services. There is a need for quantitative analysis to see the completeness of filling out medical record documents. The purpose of this study was to determine the completeness of filling out outpatient medical record documents. This study uses a descriptive quantitative research method with a population of outpatient medical record documents and a sample of 97 medical record files with saturated sampling data collection techniques by means of checklist observations. The results of the quantitative analysis research at the Cakranegara Public Health Center were found to be incomplete in filling outpatient medical record documents. The highest incompleteness in the items of professional degrees of nurses, doctors and illegible writing is 78 medical record documents (78%), and the lowest incompleteness in name and medical record number items is 97 complete medical record documents (100%). Based on the results of this study, it is recommended for further researchers to research specifically for medical record documents in general polyclinics or specifically for one disease.
Co-Authors Januari Lesmana