Appropriate and structured Medical Records documentation audit is required in measuring the achievement of Medical Record Completeness (MR) indicators in hospitals. Based on observations of the implementation of MR documentation audit in a hospital, it was found that the measured MR components varied greatly, and did not know the quantitative model of MR documentation audit. This study aims to determine the effect of Quantitative Audit Model Documentation on Completeness of MR. The hypothesis of this study is the influence of Quantitative Audit Model Documentation on Completeness of MR. This type of research is a quasi-experimental using the pretest and Posttest design, Non-Equivalent Control Group Design. The measurement of the completeness of medical records was carried out by students using conventional models and quantitative models of RM documentation audit. The population is 30 students with saturated samples. The dependent variable is MR Completeness and the independent variable is the Audit Model MR Documentation. The research instrument is a checklist. Research analysis using dependent T-test. The results of this study there are significant differences in the average value of the completeness of all components before and after the application of a quantitative audit documentation model reflects that the implementation of this model is better than the conventional model. This Quantitative Model can track each component of the medical record being audited, allowing correction of parts that can still be equipped, structured so that they can measure up to this RM completeness subcomponent.
In the Medical Record Unit of the Kembangan Regional General Hospital, the work space of the medical record unit is directly related to the active medical record storage room, the door of the medical record unit at the Kembangan Regional General Hospital does not yet have a secret key or additional security such as a fingerprint. The purpose of this study was to determine the layout of the medical record unit in maintaining the security and confidentiality of medical records at the Kembangan Regional General Hospital. This study used quantitative descriptive methods with observation and interview data collection techniques, as well as direct measurements in the workspace and storage of the medical record unit of the Kembangan Regional General Hospital using a measuring instrument in the form of a building meter, then to determine the need for storage space obtained from the calculation of shelf requirements. medical record storage using the formula according to the International Federation of Health Information Management Associations. The results of the research are in the medical record unit of the Kembangan Regional General Hospital already have standard operating procedures related to the security and confidentiality of medical records but in practice it has not been implemented optimally. Inadequate facilities and infrastructure can be seen from the current work area of 10.27 m3, it should takes 15 m3, the storage space is still minimally lit and does not meet the standards. Suggestion: it is better if standard operating procedures have not been implemented to be implemented immediately.
Penjajaran merupakan pelaksanaan Rekam Medis di ruang penyimpanan sesuai dengan sistem yang digunakan. Terdapat tiga sistem penomoran rekam medis yaitu Straight Numerical Filing, Middle Digit Filing dan Terminal Digit Filing. Berdasarkan studi pendahuluan di RSUD Dr.H.Marsidi Judono saat ini menggunakan sistem penjajaran angka langsung dan berencana melakukan konversi sistem penjajaran ke sistem angka akhir. Alasan konversi karena sistem penjajaran yang digunakan saat ini masih ditemukan beberapa kekuatan seperti penggunaan rak penyimpanan yang sangat padat serta misfield yang masih sering. Penelitian ini bertujuan untuk mengetahui prosedur konversi, fasilitas untuk konversi dan tahapan pada saat melakukan konversi sistem penajajran ke sistem angka akhir di RSUD Dr.H.Marsidi Judono. Penelitian ini menggunakan jenis penelitian deskriptif dengan motode observasi dan wawancara. Hasil dari penelitian dengan tersedianya perencanaan konversi harapannya unit rekam medis RSUD Dr.H.Marsidi Judono dapat menyediakan SPO konversi sesuai dengan draf, fasilitas yang dibutuhkan dan rincian mengenai tahap perencanaan pelaksanaan konversi sistem penjajaran.
Power practitioner professional medical record is still very little compared to the needs that exist, so that the implementation of the medical records in RSIA Tiara and Clinic Taman Anggrek not run well. Management of medical records, especially on the storage system that does not meet standards, the audit has not been done and quantitative analysis of the medical records. The purpose of this activity is to formulate a method penyimpanaan document medical records and measurement documents, improve the quality of medical records, improve knowledge and skills of medical records clerk. The method used is the measurement of quantitative completeness of medical records, training and mentoring the management of the medical records in accordance knowledge and skills of the practitioner medical record with an increase of 21-23% that is by comparing the results of post-test and pre-test. It was concluded that intensive training can improve knowledge and skills of practitioners medical records.
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