Completeness Analysis of Completeness Filling and Time of Returning The Medical Record for Inpatient Patients at Regional General Hospital of Makassar City

Abstract

At Makassar City Hospital, one of the service indicators that has not been achieved is in incomplete medical record files and medical record files that are returned more than 2x24 hours after service. This study aims to analyze the implementation of the completeness of filling in and the timeliness of returning inpatient medical record files at the Makassar City Hospital. This type of research is mixed methods research. The study design used a cross-sectional approach. The study was conducted in September - October 2020. The results showed that the implementation of completeness of filling in and the timeliness of returning medical record files was still low, this has led to the accumulation of medical record files in the treatment room and delays in returning the files of inpatients to the medical record installation of the City Hospital Makassar. Training on the implementation of medical records has not been comprehensive for all officers at the Makassar City Hospital. The result of the delay in returning the documents is the delay in payment of insurance claims to the hospital. Accumulation of medical records in the treatment room from incomplete medical records and returned to the treatment room. Health workers who forget to fill in complete medical records are only given a sanction in the form of a warning during a meeting with the medical committee. Availability of SOP on filling and returning medical record files at the hospital. The facilities and infrastructure in the implementation of medical records are still insufficient for medical record employees at Makassar City Hospital. It is recommended that the hospital improve the implementation of the completeness and timeliness of returning medical record files, provide incentives or rewards for completing filling in, increase the number of computers and expand the room in the medical record installation, and review the medical record format at Makassar City Hospital

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