![]() ![]() Suggestions from this study, it is better to evaluate and monitor periodically the completeness of filling out the integrated patient progress record form. In the component of good notes, the highest is in the "no streak" section with a percentage of 26.7%. The highest incomplete authentication component is the doctor's signature with a percentage of 44.5%. In the important note’s component, it was found that 100% of the forms were filled out. The highest incomplete patient identity component consists of medical record number and patient gender with a percentage of 33.4%. From the results of the quantitative analysis of research on the completeness of filling out the integrated patient development record form for the period October to December 2018 with a sample of 180, it is known that 90% are incomplete and 10% are filled. While the specific objectives are to identify policies and standard operating procedures in the implementation of filling out the results of medical care on the integrated patient progress record form, identify incomplete filling of the integrated patient progress record form and identify the factors causing the incomplete filling of the integrated patient progress record form. The general purpose of this study was to analyze the filling of medical care results on the integrated patient development record form at Yadika Kebayoran Lama Hospital. ![]() Undang-Undang Nomor.The integrated patient progress record is the documentation of care professionals about the progress of the patient's condition in an integrated form in the standard format in the patient's medical record. ![]() Undang-Undang Nomor 44 Tahun 2009 tentang Rumah Sakit ![]() Undang-Undang Nomor 36 Tahun 2009 tentang Kesehatan Permenkes Nomor 269 Undang-Undang Nomor 29 Tahun 2004 tentang Praktek Kedokteran Permenkes No 269 th 2008 Tentang Rekam Medis Selain itu, proses ini juga harus meneliti kelengkapan data sesuai penyakit pasien dan akurasi pencatatannya. Peraturan Pemerintah Nomor 32 Tahun 1996 tentang Tenaga Kesehatan. Assembling rekam medis adalah salah satu proses di unit rekam medis yang berupa mengurutkan dokumen rekam medis mulai dari gawat darurat, rawat jalan, hingga rawat inap sesuai kronologi penyakit pasien terkait. Kepmenkes Nomor 1333 Tahun 1999 tentang Standar Pelayanan Rumah Sakit Kepmenkes Nomor 034 Tahun 1972 tentang Perencanaan dan Peme liharaan Rumah Sakit Pedoman Manajemen Informasi Kesehatan di Sarana Pelayanan Kesehatan, Jakarta. Dasar-dasar Kependidikan, PT Rineka Cipta, Jakarta. Kiat Mengelola Rumah Sakit, Jakarta.įuad, Ihsan. Direktorat Jenderal Bina Pelayanan Medik, Pedoman Penyelenggaraan dan Prosedur Rekam Medis di Indonesia, Revisi II, Jakarta.ĭjojodibroto, Darmanto. Manajemen Administrasi Rumah Sakit, Jakarta.ĭepartemen Kesehatan RI. Conclusion: The conclusion of this research was the usage of electronic medical record is more savety, accurate and effective in hospitalĪditama, Tjandra. Medical can also record it becomes a tool the evidence in the investigation in a similar way manual medical record. The results showed that has certain excellence that more so than with manual medical. Result: This research gained an electronic medical record. Because of that, needed there is research on how the comparison between medical record manuals by electronic medical record if record of profit and weaknesses and how in terms of safety data storage electronic medical record compared to manual medical record and assess whether electronic medical record can be used as an instrument the evidence in the investigation in the provision of health services related to not repeat this research with methods of juridical normative. The data presented in the form of the patient medical record manually and electronic medical record, and the data it is very important to the hospital. Method:The method used in this research was normative yuridis. Objective:to determine the usage of electronic medical record in hospital. In order to to support these health services then required health information of the members of the data that is neither of the patients medical record. Backgroud: A hospital was a part of a whole system health services which aims to carry out health services, these services through the effort to healing patients. ![]()
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