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Jurnal Administrasi Bisnis Terapan (JABT)

Abstract

Background: Medical records / patient medical records are an important part in helping the implementation of health services to patients in the hospital. Based on Permenkes No. regulation 269 / Menkes / Per / III / 2008, a medical record is a file that contains records and documents about the patient's identity, examination, treatment measures and other services that have been provided to the patient. The research objective is to identify the completeness of filling medical records in the outpatient unit of RSIA Bunda Aliyah, in the context of efforts to improve health services in hospitals, medical records can also be used as evidence of disease progression, care that has been given and as a means of communication between Health workers. Method: quantitative research by taking a sample (purposive sampling) as many as 328 medical records were taken at BIA Aliyah Hospital. Results: obtained complete outpatient medical record components complete as a whole (94%) while the incompletely filled (6%) file. From the completeness of outpatient medical record data, there are the top 3 that are not completely filled, including the names of doctors as many as 97 files, as much as 63 files of management recommendations, and the number of participants / cards as many as 54 files.

References

Departemen Kesehatan RI, 2006. Pedoman Penyelenggaraan dan Prosedur Rekam Medis Rumah Sakit di Indonesia. Edisi II. Jakarta: Direktorat Jenderal Bina Pelayanan Medik. Erfavira, Avita. 2012. Perbedaan Kelengkapan Pengisian Rekam Medis Antara Instansi Rawat Jalan Dan Instalasi Rawat Darurat di Poli Bedah RSUP Dr. Kariadi. Semarang. Erwin dkk,2013. Kelengkapan Pengisian Reka Medik Rawat Jalan dan Patient Safety di RSGMP UMY. Feby Erawantini, E. N. G. Y. S. S. H., 2013. Rekam Medis Elektronik: Telaah Manfaat Dalam Konteks Pelayanan Kesehatan Dasar. Hatta, G., 2012. Pedoman Manajemen Informasi Kesehatan di Sarana Pelayanan Kesehatan Revisi Kedua. Depok: Universitas Indonesia. KEPMENKES RI, 2007. Keputusan Menteri Kesehatan Nomor 1165/Menkes/SK/X/2007. [Internet] Tersedia di: https://www.persi.or.id/images/regulasi/kepm enkes/kmk11652007.pdf [Diakses pada: 7 April 2020]. Nurgaheni Elvisa Muninggar, 2017. Studi Analisis Kelengkapan Pengisisan Formulir Resume Medis pada Rekam Medis Rawati Inap Pasien JKN di RS Orthoedi Prof. Dr. R. Soeharso, Surakarta. (skripsi) PERMENKES RI, 2008. Peraturan Menteri Kesehatan Republik Indonesia Nomor 269/Menkes/III/2008 tentang Rekam Medis. [Internet] Tersedia di: https://www.persi.or.id/images/regulasi/perm enkes/pmk2692008.pdf [Diakses pada: 7 April 2020]. Ridho, Khasib Mabrur. 2012. Analisis Faktor-Faktor Yang Mempengaruhi Kepatuhan Pengisian Rekam Medis Di Rumah Sakit Gigi Dan Mulut Pendidikan Universitas Muhammadiyah Yogyakarta. Universitas Muhammadiyah Yogyakarta. Yogyakarta. Rustiyanto, E., 2012. Etika Profesi Perekam Medis dan Informasi Kesehatan. Yogyakarta: Graha Ilmu. Sugiyanto, W. W. R. I., 2018. Analisis Kuantitatif Kelengkapan Pengisian Formulir Resume Medis Pasien Rawat Inap Tahun 2015 Di RSUD R.A Kartini Jepara. Jurnal Rekam Medis dan Informasi Kesehatan, Volume 1. UU RI No. 44, 2009. UU RI No 44 Tahun 2009 Tentang Rumah Sakit. [Internet] Tersedia di: https://www.persi.or.id/images/regulasi/uu/u u442009.pdf [Diakses pada: 7 April 2020]. World Health Organization, 1957. Definisi Rumah Sakit. [Internet] Tersedia di: www.who.int [Diakses pada: 6 April 2020]. NISO. 2004. Understanding Metadata. Bethesda, MD: NISO Press, National Information Standards Organization.http://www.niso.org/publication s/press/UnderstandingMetadata.pdf ISO 23081-1:2006 (E) Information and documentation-Records management processes-Metadata for records pada https://portal.tcu.gov.br/lumis/portal/file/file Download.jsp?fileId=8A8182A24F0A728E0 14F0AF411582250

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