Analisis Kualitatif Dokumen Rekam Medis Rawat Inap Pada Pasien Tuberkulosis Paru

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“…Populasi adalah keseluruhan objek penelitian atau sumber data yang diperlukan dalam suatu penelitian [12]. Dalam penelitian ini yang menjadi populasi yaitu berkas rekam medis rawat inap pada bulan Januari sampai dengan Agustus tahun 2022 di RSUD Kabupaten Aceh Tamiang sebanyak 1.840 rekam medis rawat inap [13].…”

Section: Metode Penelitianunclassified

“…Teknik pengambilan sampling yang digunakan pada penelitian ini adalah teknik probability sampling jenis pengambilan sampel acak sederhana (Simple Random Sampling). Variabel adalah sesuatu yang digunakan sebagai ciri, sifat, atau ukuran yang dimiliki atau didapatkan oleh suatu penelitian tentang sesuatu konsep pengertian tertentu [12]. Variabel pada penelitian ini adalah kelengkapan dokumen rekam medis rawat inap di RSUD Kabupaten Aceh Tamiang.…”

Section: Metode Penelitianunclassified

“…Penelitian [12] di Rumah Sakit Permata Medika Semarang ditemukan bahwa hasil untuk kelengkapan dan kekonsistensian diagnosa menunjukkan 45 (55%) lengkap dan 19 (30%) tidak lengkap. Penelitian [13], menunjukkan bahwa dari 77 dokumen rekam medis kasus persalinan Caesarean Section di RSUD Ratu Zalecha Martapura terdapat pada kelengkapan diagnosa 62 (80,5%) dokumen lengkap dan 15 (19,5%) tidak lengkap, kemudian pada kekonsistenan diagnosa 73 (94,8%) dokumen konsisten dan 4 (5,2%) tidak konsisten, kemudian pada kelengkapan informed consent 35 (45,5%) dokumen lengkap dan 42 (54,5%) tidak lengkap, kemudian dalam keterbacaan diagnosa 48 (62,3%) terbaca dan 29 (37,7%) tidak terbaca.…”

Section: Pembahasan Review Kelengkapan Dan Kekonsistenan Diagnosaunclassified

“…Penelitian [18] masih terdapat dokumen rekam medis tuberkulosis paru di RSUD Tongas Probolinggo masih belum lengkap dan akurat. Salah satunya terdapat pada analisis kualitatif administratif yaitu terdapat penulisan alamat pasien yang tidak lengkap 100%, dikarenakan perawat kurang memperhatikan dan mengingatkan pasien/wali dalam pengisian lembar informed consent.…”

Section: Review Adanya Informend Consentunclassified

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Analisis Kualitatif Pengisian Rekam Medis Rawat Inap Di Rumah Sakit Umum Daerah Kabupaten Aceh Tamiang Tahun 2022

Ritonga¹,

Hasibuan²,

Putri³

2023

JIPIKI

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Completeness of filling out medical records in hospitals is a must for health workers and can be done using qualitative analysis. The purpose of this study was to determine the qualitative analysis of filling in inpatient medical records at the Aceh Tamiang District General Hospital. This research is a descriptive research with a quantitative approach. The research was conducted at the Aceh Tamiang District Hospital. The population in this study was 1,840 and the sample obtained was 95 inpatient medical records. The results showed that the review of the completeness and consistency of the diagnosis was 90 (95%) accurate and 5 (5%) inaccurate, namely in the inpatient doctor's notes. In the notes and nursing care and nursing diagnoses there were 87 (92%) complete and 8 (8%) incomplete. Review of the consistency of recording the diagnosis, there were 85 (89%) complete and 10 (11%) incomplete. There are 83 medical records (87%) accurate and 12 (13%) inaccurate. Incomplete and inaccurate filling of inpatient medical records is found in the consistency of development records and nursing care. There were 82 (86%) complete and 13 (14%) incomplete records of things that were carried out during treatment and treatment, namely on evidence of implementation of treatment plans, instructions and drug changes, and actions taken which were filled out by nurses. Review of informed consent from 16 inpatient medical records, there were 14 (87%) complete and 2 (13%) incomplete, namely the completeness of the contents of the informed consent filled out by nurses. Review of medical methods or practices, there are 84 (88%) complete and 11 (12%) incomplete, namely on the date and time, the signature / initials is easy to read filled in by the doctor

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Section: Metode Penelitianunclassified

Section: Pembahasan Review Kelengkapan Dan Kekonsistenan Diagnosaunclassified

Section: Review Adanya Informend Consentunclassified

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Analisis Kualitatif Pengisian Rekam Medis Rawat Inap Di Rumah Sakit Umum Daerah Kabupaten Aceh Tamiang Tahun 2022

Ritonga¹,

Hasibuan²,

Putri³

2023

JIPIKI

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“…The results of the review of recording things that were done during care and treatment were in accordance with Sudra (2020), namely, in general, good quality medical records are expected to be AC21R4A1, namely Accurate, Complete, Consistent, Informative, Rational, Relevance, Reassurance, Responsible, and Accessible. Identification of aspects of supporting examinations, namely as many as 19 medical record documents where there were no X-ray examination results from 19 patients who had X-ray examinations (Nuraini, et al, 2020). The implementation of treatment and care based on medical science or nursing science can only be carried out by health workers who have the expertise and authority to do so (Republic of Indonesia, 2009).…”

Section: Qualitative Analysis Of Inpatient Medical Record Documents I...mentioning

confidence: 99%

Qualitative Analysis of Medical Record Documents in Inpatient Patients in the Public Health Center

Nugraheni,

Kumar,

Azizah

2023

PICNHS

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The community health center is one of the first level health service facilities that is required to maintain medical records. Medical record is a document that contains patient identity data, examinations, treatment, actions, and other services that have been given to patients. Based on the Regulation of the Minister of Health of the Republic of Indonesia Number 24 of 2022 concerning medical records, Article 18 states that medical records are analyzed quantitatively and qualitatively. Qualitative analysis aims to ensure complete and accurate medical record data. Objective: The research objective was to determine the completeness and consistency of medical records based on six reviews. Method: This type of research is descriptive research with a retrospective approach. The population is 432 inpatient medical record documents, sample 81 inpatient medical record documents using simple random sampling technique. Collecting data using interviews and observation. Data processing, data presentation and data analysis were carried out on quantitative data and qualitative data in a non-statistical or descriptive manner in tabular and textular forms. Results: The results of the study: 1) review of the completeness and consistency of diagnosis by 71 (88%), 2) review of the consistency of recording diagnoses by 80 (99%), 3) review of things done during care and treatment by 81 (100%), 4 ) review of 8 forms of informed consent by 8 (100%), 5) review of recording techniques by 71 (88%), and 6) review of potential compensation matters by 66 (81%). Conclusions: The results of a qualitative analysis of medical record documents based on the six highest reviews were on the review of recording things that were done during care and treatment as well as the review of complete informed consent, namely 81 (100%), while the lowest review was on the review of things that had the potential for compensation, namely 66 (81 %). The researcher's suggestion to improve the completeness and consistency is to increase the commitment of Caring Professionals (doctors, midwives, nurses, medical recorders) regarding the importance of the completeness and consistency of medical records and the implementation of comprehensive and continuous quantitative and qualitative analyzes.

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Analisis Kuantitatif Dan Kualitatif Kelengkapan Rekam Medis Pasien Rawat Inap Kasus Pneumonia Di Rumah Sakit Daerah Mangusada Kabupaten Badung-Bangli

Farmani

2023

Maintekkes

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Laporan 10 besar penyakit di instalasi rawat inap RSD Mangusada Kabupaten Badung tahun 2019 yang menempati urutan pertama adalah penyakit Pneumonia dengan jumlah kunjungan yaitu sebanyak 1.369 pasien. Tujuan dari penelitian ini adalah menganalisis rekam medis rawat inap pasien pneumonia di RSD Mangusada Kabupaten Badung tahun 2019 baik secara kuantitatif ataupun kualitatif. Jenis penelitian ini adalah kuantitatif dengan pendekatan cross sectional dengan teknik pengumpulan data melalui observasi dan dokumentasi. Populasi pada penelitian ini adalah 342 rekam medis (RM) pasien pneumonia, dengan jumlah sampel sebanyak 100 RM yang dipilih secara systematic random sampling. Data dianalisis secara deskriptif berdasarkan aspek kelengkapan kuantitatif dan kualitatif. Hasil analisis kuantitatif RM diperoleh kelengkapan data sosial pasien (demografi) 7%, kelengkapan bukti rekaman 40%, keabsahan rekaman 35%, tata cara pencatatan 5%. Sedangkan untuk analisis kualitatif administratif yaitu kejelasan masalah dan kondisi atau diagnosis 49%, masukan konsisten 83%, alasan pelayanan 100%, telaah rekaman 6%, persetujuan tindakan kedokteran (Informed Consent) 100%, dan biaya perawatan 100%. Berdasarkan hasil analisis kuantitatif dan kualitatif pada masing-masing formulir menunjukkan bahwa seluruh rekam medis dinyatakan tidak lengkap.

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Analisis Kualitatif Dokumen Rekam Medis Rawat Inap Pada Pasien Tuberkulosis Paru

Cited by 3 publications

References 0 publications

Analisis Kualitatif Pengisian Rekam Medis Rawat Inap Di Rumah Sakit Umum Daerah Kabupaten Aceh Tamiang Tahun 2022

Analisis Kualitatif Pengisian Rekam Medis Rawat Inap Di Rumah Sakit Umum Daerah Kabupaten Aceh Tamiang Tahun 2022

Qualitative Analysis of Medical Record Documents in Inpatient Patients in the Public Health Center

Analisis Kuantitatif Dan Kualitatif Kelengkapan Rekam Medis Pasien Rawat Inap Kasus Pneumonia Di Rumah Sakit Daerah Mangusada Kabupaten Badung-Bangli

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