Penyebab Ketidaklengkapan Resume Medis Rawat Inap di RSU DR. H. Koesnadi Bondowoso

Ida Ayu Kurnia Dewi; Sabran; Atma Deharja; Demiawan Rachmatta Putro Mudiono

doi:10.47134/mpk.v1i2.6011

Authors

Ida Ayu Kurnia Dewi Politeknik Negeri Jember
Sabran Politeknik Negeri Jember
Atma Deharja Politeknik Negeri Jember
Demiawan Rachmatta Putro Mudiono Politeknik Negeri Jember

DOI:

https://doi.org/10.47134/mpk.v1i2.6011

Keywords:

Incomplete, Resume, Inpatient

Abstract

Total of 33% of 194 medical resume files experienced incomplete filling in the first quarter and second quarter of 2022. The purpose of this study was to analyze the factors causing incompleteness in inpatient medical resumes at Dr. H. Koesnadi Bondowoso Hospital. The research method applied was qualitative using data collection techniques through documentation, observation, and interviews. The research subjects consisted of the head of medical records, 3 doctors, 3 nurses, 3 admins, and 1 assembling medical recorder. The results of the study namely the lack of discipline of doctors in filling out medical resumes, the lack of knowledge of officers regarding filling completeness, there are doctors who have multiple job descriptions, there is no SOP for the completeness of filling out medical resumes, and there are still officers who do not follow the socialization of the SOP for the completeness of filling. The improvement efforts obtained are conducting socialization related to filling, cooperation between nurses and admins to remind doctors, doctors immediately fill out resumes after outpatient clinics, conducting training on filling completeness, limiting working hours and the number of patients handled by doctors, making SOPs for the completeness of medical resumes, and re-socializing SOPs.

References

Aluko, O. (2022). Statistical Methods of Handling Ordinal Longitudinal Responses with Intermittent Missing Data. Universal Journal of Public Health, 10(6), 555–562. ISSN 2331-8880. https://doi.org/10.13189/ujph.2022.100601

A. K. D. Aprilia, I. Nurmawati, and R. A. Wijayanti. (2020). “Identifikasi Penyebab Keterlambatan Penyediaan Dokumen Rekam Medis Rawat Jalan di Rumah Sakit Husada Utama Surabaya Tahun 2020.” J-REMI: Jurnal Rekam Medis dan Informasi Kesehatan, 1(4), 630–638. https://doi.org/10.25047/j-remi.v1i4.2130

A. R. T. Wardana and S. Sugiarsi. (2017). “Analisis Kelengkapan Pengisian Formulir Resume Medis Pada Kasus Abortus Imminens.” Jurnal Rekam Medis, XI(2), 1–7.

A. Sabela Hasibuan and G. Malau. (2019). “Ketidak Lengkapan Dokumen Rekam Medis Rawat Inap Pada Pasien Diabetes Mellitus di RSU Imelda Medan.” Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda, 4(2), 675–679. https://doi.org/10.52943/jipiki.v4i2.92

A. S. Wiguna and S. S. Matondang. (2018). “Keluar Pasien Rawat Inap di Rumah Sakit Umum Madani Medan Tahun 2018.” Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda, 2018(1), 409–416. https://doi.org/10.52943/jipiki.v3i1.56

Assi, C. C. (2019). Mortality Rate and Mid-Term Outcomes of Total Hip Arthroplasty Using Dual Mobility Cups for the Treatment of Femoral Neck Fractures in a Middle Eastern Population. Journal of Arthroplasty, 34(2), 333–337. ISSN 0883-5403. https://doi.org/10.1016/j.arth.2018.10.030

Beck, P. (2022). Rupture of the Pectoralis Major Muscle in Amateur Athletes: A Rare Injury or Often Overlooked? Sportverletzung Sportschaden, 36(3), 155–159. ISSN 0932-0555. https://doi.org/10.1055/a-1754-4524

Bradley, K. L. (2021). Role of Unfolded Proteins in Lung Disease. Thorax, 76(1), 92–99. ISSN 0040-6376. https://doi.org/10.1136/thoraxjnl-2019-213738

Chang, Y. (2021). Dormant Mechanisms Reveal the Clinical Significance of Tumor Dormancy: A Narrative Review. Annals of Blood, 6. ISSN 2521-361X. https://doi.org/10.21037/aob-20-46

Esraida Simanjuntak, L. W. O. S. (2018). “Faktor-Faktor Penyebab Terjadinya Missfile di Bagian Penyimpanan Berkas Rekam Medis Rumah Sakit Mitra Medika Medan Tahun 2017.” Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda, 3(1), 370–379. https://doi.org/10.52943/jipiki.v3i1.51

Farr, S. (2022). Open Release of Pediatric Trigger Thumb. JBJS Essential Surgical Techniques, 12(2). ISSN 2160-2204. https://doi.org/10.2106/JBJS.ST.21.00053

Fiocchi, A. (2021). SARS-COV-2, Can You Be Over It? World Allergy Organization Journal, 14(2). ISSN 1939-4551. https://doi.org/10.1016/j.waojou.2021.100514

G. Kencana, G. Rumengan, and F. Hutapea. (2019). “Analisa Kepatuhan Pengisian Berkas Rekam Medis di Instalasi Rawat Inap Rumah Sakit X.” Jurnal Manajemen Kesehatan Yayasan RS Dr. Soetomo, 5(1), 27. https://doi.org/10.29241/jmk.v5i1.127

G. Susanty, Rudiansyah, and A. Rudi. (2022). “Gambaran Perilaku Petugas Kesehatan Dalam Pengisian Kelengkapan Dokumen Rekam Medis di Puskesmas Sungai Durian.” Jupermik, 5(1), 19–23.

H. Tini and D. Maulana. (2018). “Tinjauan Ketidaklengkapan Pengisian Resume Medis Pasien Rawat Inap di RS Setia Mitra Tahun 2018.” Medical Record, 5(1), 9.

Kementerian Kesehatan Republik Indonesia. (2022). Peraturan Menteri Kesehatan Nomor 24 Tahun 2022 Tentang Rekam Medis. pp. 2003–2005.

Khasanah, L. (2021). “Evaluasi Pelatihan Peningkatan Kompetensi Petugas Rekam Medis di Puskesmas Cangkol.” Suara Forikes, 12, 511–515. http://dx.doi.org/10.33846/sf12429

M. A. Rahmawati, N. Nuraini, and D. A. Hasan. (2020). “Analisis Faktor Penyebab Keterlambatan Penyediaan Dokumen Rekam Medis Rawat Jalan di RSU Haji Surabaya.” J-REMI: Jurnal Rekam Medis dan Informasi Kesehatan, 1(4), 511–518. https://doi.org/10.25047/j-remi.v1i4.2000

Maria Ulfa, H., (2018). “Analisa Kelengkapan Informed Consent Tindakan Operasi di Rumah Sakit Sansani Pekanbaru.” Jurnal INOHIM, 6(1), 21–26.

Mende, K. (2023). Early Postoperative Recovery after Modified Ultra-Minimally Invasive Sonography-Guided Thread Carpal Tunnel Release. Journal of Personalized Medicine, 13(4). ISSN 2075-4426. https://doi.org/10.3390/jpm13040610

S. J. Swari, G. Alfiansyah, R. A. Wijayanti, and R. D. Kurniawati. (2019). “Analisis Kelengkapan Pengisian Berkas Rekam Medis Pasien Rawat Inap RSUP Dr. Kariadi Semarang.” Arteri: Jurnal Ilmu Kesehatan, 1(1), 50–56. https://doi.org/10.37148/arteri.v1i1.20

UU RI. (2009). Undang-Undang Republik Indonesia Nomor 44 Tahun 2009 Tentang Rumah Sakit. pp. 1–41.

Wei, J. J. (2019). Over-the-Scope-Clip Applications for Perforated Peptic Ulcer. Surgical Endoscopy, 33(12), 4122–4127. ISSN 0930-2794. https://doi.org/10.1007/s00464-019-06717-x

Xiao, H. (2022). Unequal Impact of the COVID-19 Pandemic on Paediatric Cancer Care: A Population-Based Cohort Study in China. Lancet Regional Health – Western Pacific, 19. ISSN 2666-6065. https://doi.org/10.1016/j.lanwpc.2021.100347