Analisis Kuantitatif Kelengkapan Pengisian Formulir Resume Medis Pasien Rawat Inap Tahun 2015 Di RSUD R.A Kartini Jepara

Abstract

The medical resume form is a form of brief explanation or summarizes any important information about the disease, the examination and its treatment. In the filling of medical resume at RSUD R.A Kartini Jepara still found incompleteness on the patient's social identity, important reports and the blanks. The purpose of this study was to identify patient identification reviews, reviews of important reports, review authentication and review the correct recording or documentation. The method used is descriptive method and data collection using observation and documentation study. Based on the results of research and discussion of the average completeness of each review, the average completeness is the highest in the identification of the patient is 82.3%, while for the lowest average is on the review of important reports that is 25.35%. Review the percentage authentication of 54.7% while for the correct recording or document review reaches 65%. From this study it can be concluded that the hospital needs to make improvements to fill the form, especially on medical resume so that the function of medical resume can be held well.