FILLING OUT THE PATIENT MEDICAL RESUME SHEET AT HOSPITAL X

Abstract

Problem: Analysis of medical record documentation is a review of certain parts of the contents of medical records with the aim of finding specific deficiencies related to recording medical records. Based on an initial survey of 10 sheets of medical resumes, it was found that 4 (40%) were complete (patient identification, important reporting and authentication) and 6 (60%) were incomplete. This is because medical record officers only assemble or sort one page to another without conducting a quantitative analysis of medical record files to check the completeness of the files supported by the absence of SOPs, and the absence of reporting on the completeness of filling in medical record files, which has an impact on the decline in the quality of hospital services.Objective: Knowing how to fill out a medical resume sheet at hospital X.Method: This type of research is observational research with a descriptive design. The population in this study was 438 medical resume sheets in 2024 and a sample of 209 with a simple random sampling technique. The research data used secondary data processed univariately using frequency distribution.Results: Of the 209 medical resume sheets, 23(15%) were incomplete patient identification, 132(64%) were incomplete important reporting, 113(54%) were incomplete authentication. It is expected that the hospital will compile an SOP on documentation analysis and socialize it to be a guideline for assembly officers to conduct medical record documentation analysis.