| Summary: | Background: Result of evaluation of the quality objectives in July-December 2012, the percentage of incomplete documentation of medical records is 5,827%. Incompleteness can be translated to 0,03% for social data doctor�s resume sheet, 2,093% for the writing of the evidence on the record doctor�s resume sheet, 3,698% for the authentication of the doctor�s resume sheet, and 0,005% on the registration procedures of admission and dischage summary. Incompleteness doctor�s resume sheet can affect in service, insurance claims, and it can affect the medical records personnel job. Remember the importance of doctor�s resume sheet, the impact of incompleteness and the points in the accreditation assessment that relate to medical resume.
Purpose: The purpose of this study was to determine the charging doctor�s resume sheet in fulfillment accreditation standards, determine the cause incompleteness doctor�s resume sheet and efforts of medical records personnel and related professions overcome of incompleteness doctor�s resume sheet.
Methods: This study used a qualitative descriptive approach, with a cross-sectional study design. Techniques of data collection using interviews, observation, and documentation. For the validity of the data using triangulation techniques. Result: Charge doctor�s resume sheet in fulfillment accreditation standards are filled out by DPJP after the patient goes home, doctor�s resume sheet at Grhasia Psyciatric Hospital DIY have instructions for follow-up, a copy of the summary care patients documented in the medical record in the doctor�s resume sheet, a copy of doctor�s resume sheet given to patients if requested by the patient's family, doctor�s resume sheet copy given to the referring medical practitioner with a copy on reply sheet references, in the Grhasia Psyciatric Hospital DIY no policy that specifies when the patient resumes return must be completed and entered into the patient's medical record, doctor�s resume sheet at Grhasia Psyciatric Hospital DIY in it already include the reasons patients are treated, diagnosis and concomitant diseases, physical findings and other things that are important, diagnostic and therapeutic procedures that have been carried out, and the medicinal mentosa medika time home, state / status of current patients home, and instructions for follow-up. For completeness percentage resume charging sheet physicians was 57% for patients identity component, 24% for component recording of evidence, 3% for the validity of the recording component, and 16% for the recording procedure. Cause incompleteness resume sheet is the number of physicians and rushing doctors, lack of socialization related charging of doctor�s resume sheet, and the absence of reward and punishment. Efforts made in overcome of incompleteness doctor�s resume sheet are assembling medical records and perform quantitative analysis and given the memo. After it the medical record was delivered to the doctor's office. Doctors try to complete as soon as possible. If there is a doctor who holiday / leave charging can fill in the name of the doctor in charge. Committee on the medical record did reprimand the doctor concerned and evaluation.
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