Analisa Kelengkapan Pendokumentasian Identifikasi Bayi Baru Lahir di Rumah Sakit Bhayangkara TK III Wahyu Tutuko Bojonegoro

Abstract

Background: In medical records, there is a need for improvement in the analysis of medical record documents, because complete medical record files can be used as a reference for health services, protecting legal interests, in accordance with existing regulations. Based on a preliminary survey at the Bhayangkara TK.III Hospital, Wahyu Tutuko, Bojonegoro, 10 incomplete medical record documents were found. Research Objectives: Analyzing the Completeness of Documentation for the Identification of Newborns at Bhayangkara Hospital TK.III Wahyu Tutuko Bojonegoro. Research Methods: This study used a quantitative descriptive research type, with a retrospective approach. The research population, namely medical record documents for newborns in 2019, amounted to 123 medical record documents with a sample of 55 medical record documents. The data collection method used is observation and interviews. Research Results: The results showed that the completeness of the medical record files for newborns at Bhayangkara TK.III Hospital Wahyu Tutuko Bojonegoro, from 55 medical record documents, there were 24 documents (43.64%) that were complete, while 31 documents were incomplete ( 56.36 %). One of the factors that cause incomplete medical records for newborns is that there is only one special officer to carry out completeness checking activities so that many files are incomplete, and files received from the baby care room are directly stored on the filing shelf. Conclusion: From the results of these percentages, it is known that the level of completeness of the medical records of newborns at Bhayangkara TK.III Hospital Wahyu Tutuko Bojonegoro is still low, so it needs to be improved so that the results obtained are complete and optimal for hospital reporting.