Analisis Kelengakapan Pendokumentasian Pelayanan Kebidanan Di Wilayah Kerja Puskesmas Lubukbuaya Kota Padang

Abstract

<jats:p>&lt;p&gt;&lt;em&gt;Midwifery documentation has a large portion in the patient's clinical record that informs certain factors or situations during the midwifery care provided. In Puskesmas Lubuk Buaya, there are 94.12% of midwives who dont report the documentation of midwifery perfectly in according to requirements that must be reported. The research aims to analyze problems related to the completeness of midwife documentation of midwifery services in the work area of Puskesmas Lubuk Buaya. The method of this study is qualitative. This research was conducted in August - October 2019. The results of research was founded, Puskesmas Lubuk Buaya had followed according to government policy. Funding, human resources and infrastructure are quite adequate, just how to use and optimize it and how disciplined the officers are in using it. The planning of the Puskesmas Lubuk Buaya has been going well. However, for the completeness of documentation of midwives in providing midwifery services, SOAP documentation has not been applied to each patient. Midwives tend not to make SOAP because SOAP is not a mandatory report that must be reported every month to the Puskesmas. Evaluations are reviewed when submitting monthly report collections which are then recapitulated by the Puskesmas in the Puskesmas monthly report.&lt;/em&gt;&lt;/p&gt;</jats:p>

Legal Consistency of Health Personnel in Making Medical Records

“…Factors that affect incompleteness in making medical records in their research (Nurhaidah & Harijanto, 2016) are doctors, nurses, or midwives who lack discipline, and there is no evaluation (Nurhaidah & Harijanto, 2016), supported by research (Swari et al, 2019) Factors that affect incompleteness in making medical records are factors officers, procedural factors, tools, and motivation factors (Swari et al, 2019). Research conducted by Zulfita Eka (2020) found that midwives in Lubuk Buaya Padang complete documentation only on documentation that had been templated by the Health Office, but in making service documentation with SOAP (Subjective Objective Analysis and Planning), it was incomplete, completing only for the need to collect points in order to find SKP (Professional Credit Unit) (Zulfita et al, 2020). Based on research conducted by Eka Desi Purwanti that nurses at RS Haji Jakarta found that the documentation carried out by nurses was not fully in accordance with SPO (Standard Operating Procedures) for nursing care documentation (Purwanti, 2012).…”