Analisis Kuantitatif Dan Kualitatif Kelengkapan Rekam Medis Pasien Rawat Inap Kasus Pneumonia Di Rumah Sakit Daerah Mangusada Kabupaten Badung-Bangli

  • Putu Ika Farmani Program Studi Manajemen Informasi Kesehatan Universitas Bali Internasional

Abstract

Pneumonia was the first disease of top ten disease of inpatients aat Mangusada Regional Hospital in Badung Regency in 2019 with a total of 1,369 patients. The purpose of this study was analysed the inpatient medical records(MR) of pneumonia patients in Mangusada Regional Hospital in Badung Regency in 2019 both quantitatively and qualitatively. This type of research is quantitative with approach cross sectional with data collection techniques through observation and documentation. The population in this study was 342 MR of pneumonia patients, with a total sample of 100 MR. Data was analysed descriptively based on aspect of quantitative and qualitative completeness analysis. The results of the quantitative analysis of MR obtained the completeness of patient social data (demographic) was 7%, recording evidence was 40%, validity of the record was 35%, complete of recording procedure was 5%. As for the administrative qualitative analysis obtained the completness, namely the clarity of the problem and condition or diagnosis was 49%, consistent input was 83%, the reasons for service was 100%, the review of records was 6%, approval of medical action (Informed Consent) was 100% and maintenance fee 100%. Based on the results of quantitative and qualitative analysis on each form shows that all medical records are declared incomplete.

Published
2023-12-10
Section
Articles