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Abstract

Returning medical records is the beginning of processing patient medical records. The return of the patient's medical record is one of the quality standards of the medical record unit, which must be done a maximum of 1x24 hours after the patient going home. This study aims to determine the achievement of quality standards of medical record files for inpatients at Z Hospital, time of return, time of delay and factors causing delays in medical records. The research was conducted at the Medical Record Unit of Z Hospital with a mixed methods approach. Data collection was carried out from March to April 2021, using secondary data originating from 390 medical files based on the documentation of inpatient medical record files in February 2021 and primary data originating from interviews. The data was processed using a spreadsheet program, with univariate analysis. The results showed that the achievement of quality standards for inpatient medical documentation at Z Hospital was 40.77%. The average time is 3.91 days and the average delay time is 4.90 days. The cause of the delay is the doctor's discipline factor in filling out resumes, incomplete documents in patient status, and human resources.

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