Completeness of Medical Record Documents for Inpatient Kidney Failure at the Hospital

Tasya Aisyah Adinda Raekha; Sri Wahyuningsih; Nor Akmar Bt Mohd Yahya

doi:10.37287/picnhs.v3i1.1147

Tasya Aisyah Adinda Raekha Universitas Duta Bangsa Surakarta
Sri Wahyuningsih Universitas Duta Bangsa Surakarta
Nor Akmar Bt Mohd Yahya University Malaysia of Computer Science & Engineering

DOI: https://doi.org/10.37287/picnhs.v3i1.1147

Keywords: analysis quantitative kidney failure, completeness of inpatient, medical record documents

Abstract

Health service providers are required to record all services provided to patients in the form of a complete medical record file. Incomplete filling of medical records can lead to misinformation used by health professionals in providing services or treatment plans. This study aims to determine the completeness of medical record documents and the factors that cause incomplete medical record documents for kidney failure.This research is a literature study. The sample in this study were 5 journals related to the completeness of medical record documents for inpatient cases of kidney failure using purposive sampling technique. The instrument in this study used the google application. Processing of data by searching on the site, collecting overall journals, journal screening and extracting data based on inclusion criteria using the Systematic Literature Review (SLR) method. The analysis was carried out using data analysis techniques, namely quantitatively. The results of the study on the completeness of medical record documents for inpatient kidney failure based on a review of patient identification, the entire journal was incomplete, 100% incomplete, mostly on the name and age items. Review reporting there is 1 journal is 100% complete, 4 journals are not complete 100% incomplete mostly on date and time items, authentication review the entire journal is not complete. 100% of the incompleteness is found in the items of the doctor's name and the doctor's signature. The review of the recording of the entire journal is not complete. 100% of the incompleteness is on the item using the fixed line on the blank form. The factor of the incompleteness of the medical resume on the inpatient document is due to the lack of accuracy of the officers infilling, lack of discipline of officers, and the absence of a clear SOP. The conclusion of this study is that from 5 journals regarding the completeness of medical record documents in terms of reviews of identification, reporting, authentication and recording, it shows that medical record documents are 100% incomplete. This is due to the lack of accuracy of officers in filling it out, lack of discipline of officers, and the absence of clear SOPs.

References

Budi, S.C. (2011). Manajemen Unit Kerja Rekam Medis. Yogyakarta: Quantum Sinergis Media.
Departemen Kesehatan RI. (2006). Pedoman Penyelenggaraan & Prosedur Rekam Medis Rumah Sakit. Revisi II. Jakarta: Direktorat Jendral Pelayanan Medik Departemen Kesehatan Republik Indonesia.
Dzulhanto, B.Y., (2018). Kelengkapan Pengisian Dokumen Rekam Medis Penyakit Hernia Dengan Metode Analisis Kuantitatif. Jurnal Manajemen Informasi dan Administrasi Kesehatan (J-MIAK). Vol 1 (1). Hal. 1- 10. http://journal.univetbantara.ac.id/index.php/jmiakrekammedis/article/view/121/109
Doenges, Marilynn E.dkk. (2000). Rencana Asuhan Keperawatan & Pedoman Untuk Perencanaan dan Pendokumentasian Perawatan Pasien. Edisi III.Alih Bahasa: I Made Kriasa.EGC.Jakarta
Kemenkes RI. (2008). Peraturan Menteri Kesehatan RI NO269/MENKES/PER/III/2008. Tentang Rekam Medis. Jakarta: Menteri Kesehatan Republik Indonesia.
Lubis, Fitriyani., dkk. (2018). Tinjauan Ketidaklengkapan Pengisian Catatan MedisPada Berkas Rekam Medis Rawat Inap Pasien Penderita Diabetes Melitus Terhadap Klaim BPJS di Rumah Sakit Umum IPI Medan Tahun 2018. Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda, Vol 3.
Peraturan Pemerintah. (2004). Undang-undang No. 29 Tahun 2004. Tentang Praktik Kedokteran. Jakarta: Presiden RI.
Peraturan Pemerintah. (2009). Undang-undang No. 44 Tahun 2009. Tentang Rumah Sakit. Jakarta: Presiden RI.
Rahayu, S.N, dkk. (2013). Analisis Kuantitatif Dokumen Rekam Medis Pasien Rawat InapPada Kasus Chronic Kidney Disease Triwulan IV di RSUD Pandan Arang Boyolali. Jurnal Rekam Medis, Vol. 2 (7); Hal. 49-60.
Sabarguna. (2008). Tentang Quality Assurance Pelayanan Rumah Sakit. Yogyakarta: Sagung Seto.
Sudra, R. I. (2017). Rekam Medis. Tanggerang Selatan: Universitas Terbuka.
Susanti., dkk, (2013). Analisis Kuantitatif Dokumen Rekam Medis Pasien Rawat
Inap Kasus Chronic Heart Failure Triwulan IV Tahun 2012 Dirumah Sakit Umum Daerah Pandan Arang Boyolali. Jurnal Rekam Medis,2(7).
Ulum, M. (2019). Analisis Kuantitatif Dokumen Rekam Medis Pasien Rawat Inap Kasus Bedah di RSUD Kanjuruhan Kepanjen : Program Studi D3 Rekam Medik dan Informasi Kesehatan STIKes Widya Cipta Husada Malang. Vol. 3 No. 6; Hal. 10-18. ISSN : 2089-4228.
Wati, V.R., Harjanti. (2016). Analisis Kuantitatif Dokumen Rekam Medis Pasien Rawat Inap Diagnosis Hematemesis Melena.
Wirajaya Maha. (2019). Faktor-Faktor yang Mempengaruhi Ketidaklengkapan Rekam Medis Pasien pada Rumah Sakit di Indonesia. Jurnal Manajemen Informasi Kesehatan Indonesia. Vol.7 (2).
Zed, Mestika. (2008). Metode Penelitian Keperpustakaan : Yayasan Obor Indonesia.