Analisis Kelengkapan Pengisian Berkas Rekam Medis Pasien Rawat Inap oleh Dokter di RSUD Sultan Sulaiman Serdang Bedagai Tahun 2023

Abstract

A medical record is a document or note containing facts relating to the patient's condition, history of illness and treatment filled in by the doctor who provides health services to the patient. Complete medical records provide accurate information and can be used for administrative, legal, financial, research, educational and documentation purposes which are useful for various purposes in the hospital. The results of research at Sultan Sulaiman Regional Hospital on ten inpatient medical record files taken randomly found that 40% of medical records were incomplete. This research aims to analyze the completeness of filling in medical record files for inpatients by doctors at Sultan Sulaiman Hospital Serdang Bedagai in 2023. This type of research is qualitative research using in-depth interview methods consisting of six specialist doctors. From the results of in-depth interviews with six specialist doctors, it shows that incomplete filling in of medical record files is mostly caused by doctors being busy due to the large number of patients in a day, lack of responsibility and awareness of doctors in completing filling in medical record files, as well as lack of cooperation between doctors and officers. other health.