Kelengkapan Pengisian Ringkasan Pasien Pulang Di RSU Kharisma Paramedika Kulon Progo

Abstract

The discharge summary is a medical record form that documents essential information during a patient's treatment period. Therefore, the quality of the discharge summary needs to be maintained by conducting a quantitative analysis of medical records. By doing quantitative analysis, it can be seen that the items in the discharge summary are still incomplete so that the factors causing the incompleteness can be traced. This study aims to determine the percentage of completeness and the factors causing the incomplete discharge summary at Kharisma Paramedika Hospital Kulon Progo. The research method used is descriptive research. A quantitative data collection approach was used to interpret the results of the complete discharge summary. In contrast, a qualitative approach was used to explore the factors causing the incomplete discharge summary at Kharisma Paramedika Hospital Kulon Progo. The study population was obtained from November 2019-January 2020 as many as 352 summary returns. Samples were taken randomly with a confidence level of 0.1, so a sample of 78 summaries was obtained. The results showed that the completeness of social identity was 88.67%, important reports were 87.95%, authentication was 92.30%, and correct documentation was 94.87%. The incomplete discharge summary caused by the man factor, namely the lack of accuracy of the medical record officer and lack of understanding of the doctor, the machine factor due to the lack of a manual recording system (not yet using patient stickers/labels for patient identity on the form heading), the money factor due to lack of motivation and understanding. doctor because there is no reward. It is necessary to have the support of the hospital leadership to increase the motivation of doctors through socialization of the importance of completing the discharge summary in supporting patient safety and smooth claims, as well as the existence of rewards.