Diah, Elya Sari (2022) Tinjauan Ketidaklengkapan Berkas Rekam Medis Rawat Jalan Di Rs Tk III Dr. R Soeharsono Banjarmasin Tahun 2020. [Tugas Akhir]

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Abstract

Based on the Minimum Service Standards (SPM), a complete medical record is a medical record that has been filled out completely by a doctor within <24 hours after completing outpatient services or after an inpatient is decided to go home. Based on a preliminary study at TK.III Hospital Dr. R. SOeharsono Banjarmasin, from 18 samples of outpatient medical records it was found that 100% were incomplete. The incompleteness lies in filling in the medical record number, patient name, date of birth, date of visit, disease history, physical examination, diagnosis, disease code, and doctor's signature.This study aims to determine the incomplete filling of outpatient medical record files at TK III DR R Soeharsono Hospital Banjarmasin. This research was carried out with a descriptive method. The sample in this study were 85 medical record files of internal medicine polyclinic patients. The results of the study included the highest incompleteness criteria for the patient's disease code criteria, 85 incomplete files (100%), the patient history criteria for 48 incomplete files (56%), the criteria for date of birth / patient age 23 incomplete files (27%), criteria medical record number obtained 22 incomplete files (26%), patient name criteria obtained 22 incomplete files (26%), patient diagnosis criteria 16 incomplete files (19%), patient visit date criteria 14 incomplete files (16%) , the patient's physical examination criteria were 14 incomplete files (16%), and the lowest incompleteness was in the doctor's signature criteria 14 incomplete files (16%). The conclusion of the study was the incompleteness of the medical record file at the internal medicine polyclinic at TK III DR R Soeharsono Banjarmasin Hospital contained in filling in the disease code, disease history, date of birth / patient age, medical record number, patient name, diagnosis, date of visit, physical examination, and signs. doctor's hand. Keywords: incompleteness, medical record, outpatient, internal medicine

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