JURNAL SURYA
Jurnal Media Komunikasi Ilmu Kesehatan Faculty of Health Sciences Universitas Muhammadiyah Lamongan Web link: http://jurnal.
Analysis of The Completeness of The Medical Resume of Maternity Patients at Nashrul Ummah Lamongan Islamic Hospital Devi Salsa Yuniartha.
Suharyono.
Lilis Maghfuroh.
Atiul Impartina.
Ganda Saputra*.
Arif Banar Rizali.
Dadang Kusbiantoro Master of Health Administration Study Program.
Faculty of Health Sciences.
University of Muhammadiyah Lamongan.
Lamongan.
Indonesia
ARTICLE INFORMATION
ABSTRACT
Article process Submission: June 22, 2024 Revision : December 15, 2024 Accepted : December 30, 2024 Introduction: A medical resume is a summary of the medical services provided by a health professional, especially a doctor, during treatment until the patient is discharged, either alive or The purpose of this study is to determine the percentage and factors that cause the completeness of the medical resume of maternity patients at RSI Nashrul Ummah Lamongan.
Methods: The design in this study is a combination of sequential explanatory research that combines quantitative and qualitative research methods sequentially.
The number of samples is 72 medical resumes for the End of the Year 2022.
Results: Almost all .
%) complete patient identification fills out and a small part .
%) of 3 incomplete medical resumes.
The completeness of filling out important reporting is all .
%) fully filled and a small part .
%) of 6 medical resumes are The completeness of filling out the authentication is almost entirely .
%) complete and a small part .
%) of 2 medical resumes are not filled out completely.
The completeness of documentation based on the recording is clearly read on the medical resume sheet which is complete .
%) complete as many as 73 medical resume sheets and a small part .
%) is Conclusion: The factor causing the delay in filling out a medical resume is time constraints caused by busyness and other work demands from the doctor in charge.
The socialization of filling out the medical resume as well as Monitoring and Evaluation should be carried out to the maximum.
Co-Author Ganda Saputra muhamadgandasaputra77@gmai Master of Health Administration Study Program.
Faculty of Health Sciences.
University of Muhammadiyah Lamongan.
Lamongan.
Indonesia Cite this as:
Yuniartha.
Suharyono.
Maghfuroh.
Impartina.
Saputra.
Rizali.
Kusbiantoro, .
Analysis of the completeness of the medical resume of maternity patients at Nashrul Ummah Lamongan Islamic Hospital.
SURYA: J.
Media Komunikasi Ilmu Kesehatan, 16 .
Doi:
https://doi.
org/10.
38040/js.
Keywords: Health worker.
Knowledge.
Occupational Health and Safety (K.
SURYA Vol.
No.
December 2024
INTRODUCTION
According to the Minister of Health Regulation No.
44 of 2009, hospitals are health service providers that provide individual health services in a complete manner that provide inpatient, outpatient, and emergency services.
In article 29 paragraph 1, each hospital has the obligation to maintain medical records.
Efforts to improve health services in hospitals, starting with the orderly administration of medical records, where data on medical history is very important in supporting the process of treatment, treatment and examination.
Good medical record services are one of the medical support services in hospitals that are the basis for assessing the quality of hospital medical services (Nuraini, 2.
Medical record files are the main source of data for health services.
These data sources can be evaluated and analyzed for the purpose of planning and improving the quality of health information Hatta, .
(Sawondari.
Alfiansyah and Muflihatin, 2.
One of the analyses that can be done on inpatient medical records is through quantitative analysis.
Many inpatient medical records are still incomplete, especially on the patient's identity .
edical record number, name, date of birth/age, room, entry/exit dat.
DPJP authentication, and diagnosis documentation.
Research by Giyatno and Rizkika .
at Dr.
Djoelham Binjai Hospital also found similar incompleteness.
Of the 10 documents of retrospectively analyzed, 9 documents .
%) were incomplete on patient identification, 8 documents .
%) were incomplete on medical resumes and informed consent, and 10 documents .
%) were incomplete on nurse authentication and documentation.
In the study conducted by (Agusti.
Agustyarum and Wahyu, 2.
with the title Analysis of the Completeness of Filling in Inpatient Medical Record Documents at dr Oen Solo Baru Hospital in 2021.
The completeness of medical record file data in 2021 is not 100% complete.
SURYA Vol.
No.
December 2024 This does not meet the Minimum Hospital Service Standards.
Based on the results of a preliminary survey conducted on January 11, 2022 on 10 inpatient medical record documents, there are 4 complete documents and 6 incomplete documents, with a percentage of 60% completeness and 40% completeness.
In the initial survey conducted by researchers on December 23, 2022 at RSI Nashrul Ummah Lamongan on the Medical Resume form for Maternity Cases, there were still several Medical Resume forms in maternity cases that had not been filled out completely.
Meanwhile, the minimum service standard for hospitals according to the Minister of Health Regulation 129/2008 is that the percentage of completeness of filling out Medical Record documents must be 100%.
Based on an initial survey with data collection, 10 Medical Resume Forms for Maternity Patients were found to be 100% filled in the patient's identification, namely patient identity, medical record number and gender.
In the review, the completeness of important reporting, which is 60% incomplete, is not filled in the Health Condition Item and the items of important findings & other important findings.
In the review, the completeness of authentication is 100% complete.
In the review, the completeness of the documentation is 100% METHOD The research design used in this study is an explanatory sequential design.
The population in this study is all medical record files of inpatient maternity cases for the period October to December 2022 at RSI NU Lamongan which totals 263 medical record files.
This study uses a sampling probability sampling technique, namely random sampling using the slovin
RESULTS
Table 1 It can be known that the gender of the respondents is 3 women and 2 men consisting of 3 women, namely KIA officers with the Head of the KIA Section and the Head of the Medical Records Section and 2 male officers as assembling officers on duty.
Table 1 Characteristics of Respondents Code Responders Gender Responden P1 (Kasie KIA) Women Respondent P2 (KIA Nurs.
Women Respondent R1 (Medical Women Record Cas.
Respondent R2 (Assembling Male Office.
Respondent R3 (Assembly Male Office.
Table 2 Completeness Analysis Results Percentage of Completeness Items Total Review Type Patient Identification L % TL % Name Date of Birth 70 Medical Record No.
Gender Address Important Reporting Indications of the patient 73 100 being treated Incoming Physical Supporting Examination (Laboratory Radiolog.
Final Treatment that has been 73 100 Follow-up Authentication Date Doctor's SURYA Vol.
No.
December 2024 Name Doctor's Signature Clearly Read Justification of Error Use of Abbreviation Documentation The results of the analysis .
%) of medical resume documents still contain 3 .
%) incomplete documents including name, date of birth no.
medical record, gender and address.
Factors Causing the Completeness of a Medical Resume Factor Man The results of the Respondent's interview are known that the obstacles faced by doctors when filling are time limitations due to busyness and other work demands from the doctor in charge, this was conveyed by Respondents P2 and R1.
Factor Method The results of the interviews of all respondents said that in the implementation of filling out the medical resume at the Nashrul Ummah Lamongan Islamic Hospital, there has been no implementation of Punishment and Reward.
The implementation of Monitoring and Evaluation related to filling out medical resumes at Nashrul Ummah Lamongan Hospital has not been maximized, this was conveyed by Respondent R1.
Socialization related to medical resume at Nashrul Ummah Lamongan Islamic Hospital has not been carried out optimally, this was conveyed by respondents.
Factor Machine Based on the results of the interview, supporting tools in filling out a medical resume are available.
However, it is constrained by the system which is often error by respondents P1
and R1
DISCUSSION