| Summary: | Background : Resume is a summary of the entire term care and
treatment of patients . This sheet must be signed by the patient's treating
physician. Incomplete medical resume sheet affects the medical records
clerk job, especially the manufacture of Medical Certificate. Based on
preliminary studies in hospital . Bethesda Yogyakarta shows there are
quite a lot of sheet resume incomplete . And based on the results of
interviews incompleteness resume charging impact on the manufacture of
Medical Certificate .
Objective: To determine the percentage of completeness resume medical
inpatients and precision manufacturing of Medical Certificate in Bethesda
Hospital completeness and determine the relationship of filling
completeness resume with precision of medical sertificate in Bethesda
Hospital.
Methods: The design of this study used a descriptive research methods
with quantitative approaches and cross-sectional study design . The
population in this study is a medical resume sheet that will be used for the
manufacture of a medical certificate with a sample of 112 resumes .
Statistical analysis of the data using the Spearman Rank test .
Results: The percentage of occupancy medical resume is the identity of
the item charged at 99 % , the diagnosis was 74 % filled , action items by
37 % , 71 % history summaries , lab results by 62 % , therapy/treatment by
61 % , amounting to a state home 55 % , recommended by 32 % , on 54%
of doctors by 67 % , and the signatures of 75% . Medical Certificate of
Appropriateness manufacture accuracy percentage of 75% and the
percentage occupancy of 25% . Based on the statistical test is a significant
correlation between the completeness of medical resume charging sheet
with precision manufacture of Medical Certificate with p value = 0.053
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