TINJAUAN KELENGKAPAN PENGISIAN RINGKASAN PULANG RAWAT INAP RUMAH SAKIT SETIA MITRA
TAHUN 2021
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Institusion
Akademi Perekam Medis Dan Infokes Bhumi Husada
Author
DEDIS, YUBISTIRA
Subject
R Medicine (General)
Datestamp
2023-01-30 06:48:51
Abstract :
Dedis Yubistira, Review of Completeness of Completion of Discharge Summary of Inpatients at Setia Mitra Hospital, Case Study Report, Jakarta Bhumi Husada, D-III Program of the Academy of Medical Recorders and Health Information, 2021. 85 Pages, 9 Tables, Figures 1, and 13 Appendices . This study was conducted to find out whether there are standard operating procedures for filling out a discharge summary, the number of complete discharge summaries and to find out the factors causing the incomplete discharge summary at Setia Mitra Hospital, using a descriptive method with data collection techniques of observation, questionnaires, and interviews, the sample of this study was summary of discharge of inpatients at Setia Mitra Hospital for the period January ? March 2021 with a total of 170 discharge summaries from a total population of 294 discharge summaries. The results of the completeness of the 170 discharge summaries studied were 34 completed discharge summaries and 136 incomplete discharge summaries. There is a Standard Operating Procedure for filling out a discharge summary at Setia Mitra Hospital. The factor causing the incomplete discharge summary from the doctor's side was no problem, but the medical record officer did not review the discharge summary. In this study, it is recommended to fill out a discharge summary when the patient will go home or leave the hospital so that the patient's discharge summary is completely filled out before the medical record file is returned to the medical record room. Keywords : Completeness, summary of discharge, hospital
Dedis Yubistira, Review of Completeness of Completion of Discharge Summary of Inpatients at Setia Mitra Hospital, Case Study Report, Jakarta Bhumi Husada, D-III Program of the Academy of Medical Recorders and Health Information, 2021. 85 Pages, 9 Tables, Figures 1, and 13 Appendices . This study was conducted to find out whether there are standard operating procedures for filling out a discharge summary, the number of complete discharge summaries and to find out the factors causing the incomplete discharge summary at Setia Mitra Hospital, using a descriptive method with data collection techniques of observation, questionnaires, and interviews, the sample of this study was summary of discharge of inpatients at Setia Mitra Hospital for the period January ? March 2021 with a total of 170 discharge summaries from a total population of 294 discharge summaries. The results of the completeness of the 170 discharge summaries studied were 34 completed discharge summaries and 136 incomplete discharge summaries. There is a Standard Operating Procedure for filling out a discharge summary at Setia Mitra Hospital. The factor causing the incomplete discharge summary from the doctor's side was no problem, but the medical record officer did not review the discharge summary. In this study, it is recommended to fill out a discharge summary when the patient will go home or leave the hospital so that the patient's discharge summary is completely filled out before the medical record file is returned to the medical record room. Keywords : Completeness, summary of discharge, hospital
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