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Alex Rikki, S.Kom.,M.Kom
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Jl. Bilal No. 52 Kelurahan Pulo Brayan Darat I Kecamatan Medan Timur, Medan - Sumatera Utara Telp : (061) 66455670
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Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)
Published by Universitas Imelda Medan
ISSN : 25027786     EISSN : 25977156     DOI : https://doi.org/10.2411/jipiki
Core Subject : Health,
Health Professions Public Health
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) (p-ISSN : 2502-7786 ) (e-ISSN : 2597-7156) is a national, peer-reviewed journal. It publishes original papers, reviews and short reports on all aspects of the medical record and health information. It is aimed at all medical record and health information practitioners and researchers and those who manage and deliver medical record and health information services and systems. It will also be of interest to anyone involved in health information management, health information system, and health information technology.
Arjuna Subject : Profesi Kesehatan - Menejmen Informasi Kesehatan
Articles 241 Documents
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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.

Page 25 of 25 | Total Record : 241

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