Jurnal Informasi Kesehatan Indonesia (JIKI)
Vol 9 No 2 (2023): Jurnal Informasi Kesehatan Indonesia

Analisis Kuantitatif Dokumen Rekam Medis Rawat Inap di Rumah Sakit Ibnu Sina Kabupaten Gresik

Yuliani, Resta Dwi (Unknown)



Article Info

Publish Date
24 Nov 2023

Abstract

Medical records are data for compiling health information for both outpatient and inpatient visits. Based on the Minister of Health's decision number 129 of 2008 concerning minimum hospital service standards, recording medical record documents must be 100% complete and correct. The aim of this research is to analyze the incompleteness of inpatient medical records at Ibnu Sina Hospital, Gresik Regency based on 4 aspects, namely, the social data identification aspect, the important report aspect, the authentication aspect, and the correct documentation aspect. The population in this study is the number of inpatient medical record documents that have been deposited for the period June and July 2023, amounting to 1400 sample files obtained using random sampling techniques. Determining the sample size using the Slovin formula resulted in 100 medical record documents. This research is descriptive quantitative research. Based on the results of the analysis, identification reviews were on average complete 51%, incomplete 49%, reviews of important reports were on average complete 82.83%, incomplete 61%, authentication reviews were on average complete 66%, incomplete 34%, and On average, the correct documentation review was 61% complete, 31% incomplete. There needs to be outreach about the importance of patient identification to registration officers and all patient care providers. As well as the formation of a medical records committee and activeness of the room in monitoring the completeness of medical records Keywords: Authentication review, correct documentation review, identification review, important report review

Copyrights © 2023






Journal Info

Abbrev

JIKI

Publisher

Subject

Health Professions Nursing Public Health

Description

Jurnal Informasi Kesehatan Indonesia is a journal to disseminate various scientific papers on health development and other research of health also disseminate the conceptual thoughts or ideas and research results that have been achieved in the area of health ...