Penyebab Ketidaklengkapan Pengisian Sensus Harian Rawat Inap di Rumah Sakit “x” Kota Pekanbaru

Abstract

To achieve optimal healthier, you have to have one of the best health service is a hospital.The medical record is that began during the process of receiving hospital patients, continued the medical data recording patients for patient get medical treatment at the hospital. Are a source of daily census in patient data included in the preparation of the report of the hospital whose activity calculated from 24.00 00.00 hours and hours each day.Based on the preliminary survey they hospital “x” stated that it still uses manual system.At the time of the daily census in patient census officers still recorded in daily census forms in patient. Descriptive method with a qualitative approach. Data collection instruments in this study used observation and in-depth interviews while data analysis used an inductive method. Results There is no SOP regarding the daily census of inpatients which causes medical record officers to not have an exact reference regarding the implementation of filling out the daily inpatient census, the daily census for one day is closed at 24.00 and after that a daily census resume is made for the day in question. The census that was filled out by the nurse the next day was picked up by the medical records officer to the treatment room