Standarisasi Penggunaan Simbol Pada Dokumen Rekam Medis Pasien di Rumah Sakit X Kota Pekanbaru Tahun 2022

Abstract

The symbol is a warning sign placed on the cover of the medical record file. Based on the results of the initial survey by making observations on the Medical Record document examination of symbols, it was found that incompleteness and discrepancies were found in filling out documents in the patient's medical record. This type of descriptive research uses a qualitative approach method. The informants in this study amounted to 3 people. Data collection techniques with interviews and observations. Data processing is done by using triangulation technique, while data analysis using qualitative method. The results of the study indicate that there is no standard manual for the use of symbols in medical records and it is found that medical record documents are still not paid attention to by officers due to lack of awareness of officers. The conclusion of the study is that there is no standard guideline for the use of symbols in medical records and there is still a lack of awareness by officers.