Liyani, Tri Utami (2023) TINJAUAN TERJADINYA PENOMORAN GANDA PADA DOKUMEN REKAM MEDIS DI RUMAH SAKIT JIWA SAMBANG LIHUM TAHUN 2023. [Tugas Akhir]

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Abstract

Duplication is the duplicate number given to a patient at the time of registration at the hospital, where one patient has two or more medical record numbers. This is not in accordance with the regulations, where one patient should have one medical record number that is used for life. The purpose of this study was to identify the incidence of double numbering in medical record documents and identify the factors that cause double numbering of medical records from the man and method aspects. This research method uses a descriptive method with a qualitative approach by means of observation and interviews. Based on the results of this study, it was found that the incidence of double numbering was 2 medical record numbers (20%) in the period January - April 2023. The causative factors based on the aspects of man and method are human resources, the absence of registration officers with the last education of medical recorders, registration officers have never attended training or seminars and miscommunication between registration officers and patients. The medical record numbering system uses the Unit Numbering System and has been carried out in accordance with the SPO. In conclusion, the last educational qualification of registration officers is high school, officers have never attended medical record training, and there is miscommunication between officers and patients. Keywords: Duplication, educational qualifications, and medical record documents.

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