| Summary: | Background of problem: Because of the importance of the file sheet
inpatient medical records for inpatient care of patients, then it should
be filled as possible, as soon as the patient leave or go home. The
completeness including filling code and kind of procedure taken against
patients who had surgery done. Completeness of the medical record
filling functions to facilitate the presentation of information services to
support the planning, management, and health research. If the code
and kind of procedure is not written, it can lead to difficulties in the
indexing process and will reflect the the lack of presentation of the
statistics and resulting fault in making the report. In addition, this type
of diagnosis and procedure needs to be encoded to standardize and
used in collecting and make presentation of information acquisition
morbidity statistics become accurate and precise
Purpose of Research: determine the factors causing incomplete filling
of kind and code of procedure on the sheet at RS PKU Muhammadiyah
Yogyakarta II
Method of Research: type of study is a qualitative descriptive crosssectional
design. Subjects in this study were coding officer and Chief
Medical Record Installations. Objects in this study is the inpatient sheet
of inpatient medical record with the total is 97 sheets in period January
2013. How to determine the sample size objects using saturated
samples and sampling techniques conducted by purposive sampling.
Method of data collection using the documentation study, observation,
and interviews.
Result: charging implementing the action code on the sheet carried by
the officers of inpatient medical record. Result type and code
enforcement action charging the sheets are still incomplete
hospitalization and even emptiness. 97 sheets of inpatient medical
records retrieved from the files of inpatients who performed the action,
the percentage of inpatient sheet filled action type is 32.98% or a total
of 32 pieces, which is not fully complete is 67.01% or as many as 65
sheets, and the sheets hospitalization the code of conduct charged is
9.27% or as much as 9 pieces, while the unallocated is 90.72% or as
many as 88 sheets. Teridir causative factor of human resources,
policies and operating procedures, as well as the job description.
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