FAKTOR PENYEBAB KETIDAKLENGKAPAN RESUME MEDIS RAWAT INAP DI RUMAH SAKIT ISLAMMUHAMMADIYAH SUMBERREJO

Abstract

Background: The completeness of medical record documents, including important reports such as medical resume sheets, is very important because medical record documents are used for legal protection for medical personnel who carry out procedures in health service providing agencies. A medical resume must be filled out completely and concisely accompanied by a discharge summary or what is usually called a medical resume, which contains all important information regarding the disease, the examinations carried out and the treatment. Based on the results of a preliminary study on filling out medical resumes at the Muhammadiyah Islamic Hospital in Sumberrejo, incomplete medical resumes were still found. Methods: The research method used was a questionnaire to medical staff, direct observation of the medical documentation process, and interviews with staff involved in managing medical resumes. Results: The results of this study revealed several major factors that contribute to incomplete medical resumes, including high workload for medical staff, lack of adequate training in managing medical resumes, and lack of understanding of the importance of accurate and complete documentation. The implication of these findings is the need for improvements in medical resume management, including reducing staff workload, increasing training, and increasing awareness of the importance of appropriate documentation. Conclusions: The factors causing incomplete inpatient medical resumes at the Islamic Muhamadiyah Hospital Sumberrejo are influenced by 4 aspects, namely Man, Method, Machine and Material.