Analysis of Completeness of Filling in Completeness of Data on the Medical Resume sheet in the Inpatient Room of the Petala Bumi Regional General Hospital in 2020)

Abstract

In fact, there are still incomplete medical record files, especially in inpatient rooms, because there are still medical record files that are not filled in by nurses and doctors, especially medical resume forms. This of course causes difficulty in the administration process for inpatient claims for companies and individuals, the purpose of making a medical resume is to ensure the continuity of high quality medical services and as a useful material for doctors who accept patients when they are hospitalized again. The results of the study show that The results of the administrative completeness of the 86 medical records on the inpatient medical resume form in 2020 were the most not filled in, namely the date of discharge (91.86%), name of doctor (47.67%), condition of discharge (37.20%), exit method (30.04%), doctor's signature (30.23%), address (25.58), medical record number (0), and at least the date of entry (3.48%). The cause of incomplete medical records on the summary form of entry and exit of inpatients in Petala Bumi in 2020 is a lack of thoroughness and awareness and a lack of communication between doctors and medical record officers.