HUBUNGAN KELENGKAPAN RESUME DOKTER TERHADAP KETEPATAN PENGEMBALIAN BERKAS REKAM MEDIS RAWAT INAP DI RSJ GRHASIA DIY

• Main Authors: , INTAN KUMALASARI, , Savitri Citra Budi, SKM., M.PH.
• Format: Theses and Dissertations NonPeerReviewed
• Published: [Yogyakarta] : Universitas Gadjah Mada 2014
• Subjects: ETD
• Online Access: https://repository.ugm.ac.id/131666/; http://etd.ugm.ac.id/index.php?mod=penelitian_detail&sub=PenelitianDetail&act=view&typ=html&buku_id=72164

Background: Medical record plays a significant role in improving the quality of health services through fast and accurate documentation of medical records. Unless medical records are well-documented, medical records will not be timely returned. The Standard Operating Procedure at RSJ Grhasia DIY has strictly stipulated that medical records for inpatient service have to be returned to the Medical Record Unit 2 x 24 hours at the latest after the patient is discharged from hospital. It was found that some medical records have not been properly and appropriately completed. Consequently, some medical records have been returned later than the specified deadline of 2 x 24 hours, which is not in compliance with the standard operating procedure. Objective: To identify the percentage of medical resume completion, inpatient medical record returning, and correlation between medical resume completeness and medical record return timeliness at the inpatient service of RSJ Grhasia DIY. Method: This is a descriptive quantitative cross-sectional study. Saturated sampling was employed to include inclusion and exclusion criteria. Secondary data was collected with checklist. The independent variable is medical resume completeness while the dependent variable is timeliness of inpatient medical record return. Result : Percentage of medical resume completeness at RSJ Grhasia DIY is 33.15% in identification component, 21.56% in record proof component, 26.17% in record validity component, and 19.11% in recording method component. Percentage of medical record return timeliness at the Sinta and Srikandi wards is 96.15%. In Kresna ward it is 73.68%, 96.66% in Nakula ward, 61.53% in Sadewa ward, 100% ini Arimbi ward, and 0% in Bima ward. Spearmen Rank statistics has resulted in P value of 0.828 revealing that there is no correlation between medical resume completeness and inpatient medical record return timeiness.