| Summary: | Background : Data on computer diagnosis and the outpatient medical record file there is a mismatch. Not only are there discrepancies diagnosis data is still there but the data on a computer diagnosis and medical records in a file that is not filled by the officer. The diagnosis data is the basis for data processing outpatients. This diagnosis led to inconsistency of data inaccurate data to create reports and data outpatients top ten diseases. Objective : The general objective of this study was to determine the diagnosis of the data contained on the computer and on file in the outpatient medical record Wates Hospital. Methods : The study was a descriptive study using a qualitative approach. Using
a cross-sectional study design. Population is the subject of the medical records of
all officers and all nurses at the Polyclinic Hospital Medicine Specialist Wates, while the population of the entire data object is a diagnosis on the outpatient medical record file and all data on the computer diagnosis. Sample subjects of this study were the medical records officer, two nurses Clinic Internal Medicine
Specialist and Head of Support Services. Object samples in this study were 283 outpatient medical record file of total outpatient medical record files of patients in internal medicine specialist clinic in December 2012. Data collection was by
interview, observation, and documentation.
Results : Implementation of data entry on a computer diagnosis done by the clinic nurse specialist in internal medicine at Hospital Wates, because there is no administrative officer in internal medicine specialist clinic. Appropriate diagnosis
data between your computer and files medical records as much as 81.97%, and the diagnosis of data between computers that do not conform to the medical record file as much as 18.03%. Diagnosis of the cause of the incompatibility of
data among the computers with medical record file is not found among other
procedures governing permanent diagnosis data entry on the computer, there is writing on the diagnosis of the data file that is difficult to read medical records, nurses who do not want to fill out the data to a computer diagnosis, and
diagnosis of data that does not exist on the computer.
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