Analisa Ketidaklengkapan Catatan Medis (KLPCM) Rawat Inap Pasien Bedah Orthopedi di RSUD Sultan Sulaiman Serdang Bedagai Tahun 2018Analisa Ketidaklengkapan Catatan Medis (KLPCM) Rawat Inap Pasien Bedah Orthopedi di RSUD Sultan Sulaiman Serdang Bedagai
Abstract
Completeness of medical records is one indicator of the quality of medical records, especially inpatient medical records. The presence of incomplete problems is often found in inpatients, especially orthopedic surgery. To improve health services in orthopedic surgery patients must be based on quality medical record services. This study aims to determine the number of incomplete medical records of inpatient orthopedic surgery patients at Sultan Sulaiman Hospital Serdang Bedagai. This study uses a descriptive method that is a method of research conducted with the main objective to determine the number of incomplete medical records inpatient filling in orthopedic surgery patients. From the results of the study it was found that the incompleteness of filling in the integrated record form was 18.47%, the initial assessment was 17.39%. medical resume is 10.87% and informed consent is 11.95%. The doctor's name is19.56% and the doctor's signature is 7.60% while for the patient's identification. the anesthesia record and the operation report are filled in completely. The advice from the author is a fixed procedure Analysis of incompleteness Filling inpatient medical records needs to be revised so that all forms are analyzed. and it is necessary to carry out continuous socialization.
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