Ketepatan Penggunaan Singkatan Dan Simbol Pada Dokumen Rekam Medis Rawat Inap Diagnosis Schizophrenia

Abstract

The results of research in the form of Integrated Patient Development Record (CPPT) found that there were symbols in the guidance book which was 10 symbols or 93.41%. Besides, there was incorrect abbreviation which was 11.75% and that of which was not found in the guidance book which was 10.41%. Then continued research using a medical record document diagnosing schizophrenia. This research was aimed at identifying the accuracy of abbreviation and symbol usage. This research was descriptive research through retrospective approach. The population in this research was Inpatient Medical Record Document with Schizophrenia in the third trimester in 2017 which were 163 documents. The sample were 62 medical record documents by using systematic sampling. The research instrument was checklist through observation and documentation. The data were analyzed through collection, editing, classification tabulation, and data display. The data were analyzed through descriptive analysis. Based on the observation result and the documentation, it was found that there was incorrect abbreviation which was 13%, that of unavailable in the guidance book which was 17%. Meanwhile, it was found that the symbols that were unavailable in the guidance book which was 83%. The symbol and the guidance book possessed by RSJD Dr. Arif Zainudin Surakarta was merely one and it was not classified into symbols, abbreviation , and other signs that may be used or not. It is strongly suggested that the book should be separated into symbols and abbreviations that van be used or not. Besides, it should be conducted evaluation in the implementation of symbols and abbreviation usage, and that the book used since there were still some symbols and abbreviations that had not been stated in the book