Jurnal Kesehatan Indonesia (Jurkessia)

Analisis Kelengkapan Pengisian Resume Medis Rawat Inap Periode April di Rumah Sakit Bhayangkara Banjarmasin Tahun 2011

Khairun Nisa Ginting1, Gussa Azizah2, Dion Angger Priyatama2

Abstract
Quantitative analysis is to assess the completeness and accuracy of health records (medical records) inpatient and outpatient facilities owned by the means service. Discharge summary is all about the care and treatment of patients as has been attemted by health workers and stakeholders. In a complete medical record, may obtain information that can be used for various purposes. The purpose of this study was to calculate the percentage of completeness of charging discharge summary. This research type used descriptive analytical records in April 2011. Sampling using simple random sampling of 171 pieces of discharge summary medical records. Instruments of research using observation, interviews, and sheet checklist. The result of the completeness the obtained rate is 62,02% of discharge summary where the results obtained from the average value identification of patients. The average reaches 39,38% completeness, the completeness of vital reports that the average of its research 56,14%, authentication of writing is average its rate is 63,7% completeness, and to note that both the completeness of its 88,87%. Human resources to analyzing existing 2people and they have never trained so that the knowledge obtained from socialization in the hospital and directly study the completeness of the SOP. Standard operating procedures andpolicies for the completeness of discharge summary follow a standard operating procedure completeness file medical records.

Keywords : quantitative analysis, completeness form discharge summary

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