Faktor Faktor yang Mempengaruhi Ketidaklengkapan Rekam Medis Pasien pada Rumah Sakit di Indonesia

Abstract

The hospital is one health services that has important role to improve the health status and expected to provide quality health services. One indicator of quality service is complete medical records data and information. The complete of medical record is very important because it can affects the patient's treatment process and insurance claims. In fact there are still many medical record that have not been filled completely. This study aims to determine the factors affecting incomplete inpatients medical records at hospital in Indonesia with a systematic review. Based on the literature study, there are several factors affecting incomplete inpatients medical records that is human, tools, methods, materials and finance factor. Overall the factors are lack of communication, busy doctors and a lot of work of medical record officer, the absence of tools to print medical records form, assembling room and checklist of medical record completeness assessment, the lack of information and policy about medical records and reward and punishment system, the unstructured form of medical records, the kind of medical records form and the lack of funds to provide medical records form. Hospitals need attention these factors to maintain quality of services especially quality of patient medical records.