Analisis Kelengkapan Rekam Medis Elektronik Penyakit Demam Berdarah di Rumah Sakit Santa Elisabeth Medan Tahun 2023

Arjuna Ginting; Jev Boris; Rezekieli Zebua

doi:10.32524/jksp.v7i2.1230

Penulis

Arjuna Ginting STIKes Santa Elisabeth, Medan, Indonesia
Jev Boris STIKes Santa Elisabeth, Medan, Indonesia
Rezekieli Zebua STIKes Santa Elisabeth, Medan, Indonesia

DOI:

https://doi.org/10.32524/jksp.v7i2.1230

Kata Kunci:

Keywords: Dengue fever, Completeness, Electronic medical records

Abstrak

A hospital is a health service institution that provides complete individual health services that provide in patient, out patient, and emergency services. Hospitals can be established by the Central Government, Regional Government, or the private sector. Medical records are documents that contain patient identity data, examinations, treatments, actions, and other services that have been provided to patients. Medical records aim to improve the quality of health services, provide legal certainty in the implementation and management of medical records, ensure the security, confidentiality, integrity, and availability of medical record data, and realize the implementation and management of digital-based and integrated medical records. The purpose of this study is to analyze the completeness of medical record files of dengue fever patients on patient identity sheets, anamnesis, informed consent, medical resumes at Santa Elisabeth Hospital Medan in 2023.The type of research used is descriptive research. The sample in this study is as many as 76 medical records. Sampling was carried out using the simple random sampling method. The instrument used is a checklist sheet. The results of the study obtained a percentage of completeness for the patient's identity medical record of 88.2%, complete files, 89.5% anamnesis, informed consent of 100%, medical resume of 100%. The cause of incompleteness is due to a lack of precision and discipline in filling out electronic medical record files. It is expected that medical record officers, precision and discipline in completing medical records.

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