| Summary: | Background: Diagnosis is an important data that must be documented in the
medical record entry summary sheet is mainly an admission/discharge and a
sheet of discharge summary. The usefulness of documenting the diagnosis in
one of the two pieces to ensure continuity of medical services with high quality
and useful material for doctors who accept these patients when treated back in
the hospital, sources of data report generation, and the basis for setting rates
health insurance claims. In RSKIA PKU Muhammadiyah Kotagede still there not
filled documentation diagnosis resulting data sources only report the register
book.
Goals: this study was to analyze not filled inpatient diagnosis and determine the
factors.
Methods: This research uses descriptive research techniques with a qualitative
approach. Sample objects used were 171 inpatient medical record file summary
sheet admission/discharge and discharge summary the final quarter of 2013
with a random sample techniques are used while the sample is subject medical
records officers, amounting to 3 people, 3 doctors, 2 nurses, and 1 midwife with
a purposive sample technique.
Result: There not filled diagnosis inpatients at admission/discharge sheet of
23.98% and 35.67% for summary discharge. Not filled diagnosis in
admission/discharge sheets and summary discharge largely derived from
patients hospitalized in general pediatric wards. Cause not filled diagnosis
inpatients at admission/discharge sheet and summary discharge is a man of
factors, methods and money. Man factor is less responsible doctors, nurses and
midwives do not always check the completeness of the medical record and not
remind doctors and medical recorder does not perform the analysis of medical
record file
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