Jurnal FAKTOR-FAKTOR YANG MEMPENGARUHI KELENGKAPAN REKAM MEDIS RAWAT INAP DENGAN MENGGUNAKAN DIAGRAM FISHBONE DI RUMAH SAKIT PERTAMINA JAYA TAHUN 2017

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Jurnal FAKTOR-FAKTOR YANG MEMPENGARUHI KELENGKAPAN REKAM MEDIS RAWAT INAP DENGAN MENGGUNAKAN DIAGRAM FISHBONE DI RUMAH SAKIT PERTAMINA JAYA TAHUN 2017

Medical record is a document containing records about the identity of the patient's examination and treatment. According to the Minister of Health Regulation No. 269 of 2008 the medical record must be immediately made and completed after the patient receives health services at Pertamina Jaya Hospital in filling the medical record. medical is very important in order to achieve the goals of medical records, namely as a communication tool for evaluation of quality of payment and legal protection The data analyzed are medical records of hospitalization in May 2017 The purpose of this study is to conduct quantitative analysis of inpatient medical records and identify the factors that influence completeness of inpatient medical records using the fishbone method Research methods with descriptive methods Data collection techniques by means of observation of interviews and literature studies Samples used as many as 56 inpatient medical records obtained from the results of counting unite the proportion estimation formula Based on the results of the research by observing 56 inpatient medical records found completeness of 41 medical records 74 and factors that influence the completeness of medical records by conducting observations and interviews and categorizing factors that influence the completeness of medical records based on man factors machine material method and money Found factors that affect the completeness of the medical record that is the time to complete the medical record is not enough to have no sanctions applied lack of socialization the implementation of medical record filling is not according to operational standards procedures quantitative analysis form does not cover all components and special funding completeness record limited medical It is advisable to conduct intensive socialization of operational procedures standard for the addition of health service providers and the provision of a reward and punishment system

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