Completeness of filling medical record documents on inpatient ward, Ungaran General Hospital-Semarang, Central Java -Indonesia

Wiji Lestari; Retno Astuti; Slamet Isworo

doi:10.30574/gscbps.2020.12.1.0209

Authors

Wiji Lestari Medical Record Study Program, Faculty of Health, Dian Nuswantoro University, Semarang.
Retno Astuti Medical Record Study Program, Faculty of Health, Dian Nuswantoro University, Semarang.
Slamet Isworo Environmental Health Study Program, Faculty of Health, Dian Nuswantoro University, Semarang.

DOI:

https://doi.org/10.30574/gscbps.2020.12.1.0209

Keywords:

Quantitative analysis, Assembling, Medical record documents, Services, Returning documents

Abstract

Ungaran Hospital is a type C referral hospital in Semarang regency, therefore it must have excellent and good service, including services for patients and patient’s regularity medical records. The mechanism for filling out medical record documents is often a barrier to services which results in a delayed return of medical record documents. This study aims to determine the effectiveness of filling medical record documents in 8 wards, in January - February 2020. The purpose of this study: This study aims to determine the incompleteness of filling medical record documents which result in delays in submitting medical record documents to the assembly unit. This research was conducted from February to March 2020, with the type of descriptive research that is interviews and observations of medical records officers. The results of the study were based on the calculation of 30 medical record documents consisting of 15 inpatient medical record documents and 15 outpatient medical record documents, the checklist table used to determine the completeness of filling medical record documents. Based on the analysis of medical record documents on hospitalization which includes a review of identification, reporting, authentication, and recording of 30 medical record documents studied there were 28 complete medical record documents and 2 incomplete medical records. It is necessary to provide guidance to doctors/nurses considering the importance of completeness of the contents of medical record documents in accordance with the conditions or needs of patients.

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