(KTI) REVIEW OF THE COMPLETENESS OF FILLING IN THE INPATIENT MEDICAL RESUME ELECTRONIC MEDICAL RECORDS IN THE HOSPITAL LEVEL III 03.06.01 CIREMAI

Electronic medical records are medical records created using an electronic
system for managing medical records. Inpatient medical resumes must be filled
out no later than 2×24 hours after the patient is discharged from the hospital.
This study aims to determine the completeness of filling out inpatient medical
resumes for electronic medical records at Hospital Level III 03.06.01 Ciremai.
The type of research used is descriptive with a quantitative approach using a
checklist sheet instrument. The sample used was 95 medical resumes for inpatient
electronic medical records using simple random sampling. Data analysis used
univariate analysis and the collected results were presented in tabular form using
the frequency and time distribution formula. The research was carried out on
April 19 2024 at Hospital Level III 03.06.01 Ciremai.
The research results showed that the components that were filled in were
100% complete, namely only the patient identification review component, while
the important report review component and the authentication review component
were incomplete with 97% each.
The completeness of the medical resume does not comply with the Hospital
Minimum Service Standards (SPM), which requires that the completeness of the
medical resume must be filled in completely at 100%. This research can be used
as evaluation material for hospital management to increase the completeness of
medical resumes by holding outreach to medical personnel to fill out medical
resumes completely.
Keywords : Completeness, Medical Resume, Inpatient, Electronic Medical Record
Referecies : 29 (2018-2024)