(KTI) ANALYSIS OF COMPLETENESS OF THE DISCHARGE SUMMARY OF INPATIENTS AT MUHAMMADIYAH GENERAL HOSPITAL IN CIREBON

Medical records are health services that can be integrated using information
technology. The purpose of this study was to determine the completeness of the medical
resume form for inpatients at the Cirebon City Muhammadiyah General Hospital.
Currently, the completeness of filling out medical resumes of inpatients at the
Cirebon City Muhammadiyah General Hospital is still incomplete at 73% due to the
busyness of the doctor in charge of the patient and the patient asking for forced discharge..
The type of research used is descriptive with a quantitative approach. The
population in this study is an inpatient medical resume form. The sampling technique uses
simple random sampling. The data collection technique uses the observation method with the
research instrument used is an check list sheet. This research was conducted in the medical
records unit of the Cirebon Muhammadiyah Hospital in August 2024.
The results showed that of the 78 medical resume forms studied, as many as 21
(21%) medical resume forms were completely filled in and as many as 57 (73%) medical
resume forms were not completely filled in. Completeness of filling out medical resumes at
the General Hospital Muhammadiyah Cirebon not yet (100%) there are still components
that are not completely filled in. It is hoped that there is a need for evaluation and
socialization to medical record officers, doctors and nurses.
Keywords : Incompleteness, Medical Resume, Inpatient.
References : 20 (2009-2024)