Overview of Incompleteness of Filling out Summary Forms of in and Outpatient Medical Records on Hypertension in RSUD Lubuk Basung

Authors

  • Yulfa Yulia STIKES Dharma Landbouw Padang
  • Dian Sari Stikes Dharma Landbouw Padang
  • Oktamianiza Stikes Dharma Landbouw Padang
  • Mila Sari Stikes Dharma Landbouw Padang
  • Vitratul Ilahi Stikes Dharma Landbouw Padang
  • Kalasta Ayunda Stikes Dharma Landbouw Padang
  • Gopinda Deska Putra Stikes Dharma Landbouw Padang

DOI:

https://doi.org/10.69855/mgj.v1i2.37

Keywords:

Admission and Exit Summary, Hypertension, Medical Records

Abstract

The admission and discharge summary is a medical record form that is used to record a summary of the course of the disease from the time the patient entered the hospital until the patient was discharged. The research used is quantitative research with a descriptive approach. Data collection was carried out at Lubuk Basung Regional Hospital from 27 May to 1 July 2023., and the sample consisted of 88 entry and exit summary forms from the medical records of patients suffering from hypertension. Research through observation with a checklist table. Computerization is used to process data and carry out univariate analysis. The results of the study showed that there were still incomplete filling out of entry and exit forms on patient identification items (40.9%), important patient reports (20.5%), patient permission (12.5%), good record keeping (15.9%) . ), and scribbled and clearly legible (17.05%). The results showed that the summary of admissions and discharges for hypertensive patients was still incomplete. In conclusion, this shows that the summary of admissions and discharges for hypertensive patients is still incomplete. It is recommended to carry out evaluations and reviews, as well as outreach and evaluation with doctors, nurses and other related personnel. It mainly deals with quantitative analysis of incoming and outgoing summaries.

References

Agus Kartini, S., &Liddini, H. (2019). Review of Incompleteness Writing Medical Resume Hospitals in Public Hospital Medical Partners of the Year 2019. Imelda's Recording Scientific Journal and Health Information (Jipiki), 4(2). Https://Doi.Org/10.52943/Jipiki.V4i2.93

Baker, M., Williams, S., & Taylor, R. (2016). The role of medical records in patient care: Importance of documentation in the healthcare system. Journal of Health Information Management, 32(4), 58-65.

Chang, L., & Lee, D. (2018). Comprehensive patient documentation and its impact on hospital operations. Journal of Clinical Records, 14(2), 112-118.

Depkes Ri. (2006). Department of Health Ri. Guidelines for Maintenance and Medical Record Procedures of Indonesian Hospital RevisionIi (Jakarta : Department of Health Ri. Guidelines for Maintenance and Medical Record Procedures of Indonesian Hospital RevisionIi, 2006). Department of Health Ri. Guidelines Maintenance and Procedures Medical Records Hospitals Indonesia.

Hafizatil Qurani, A., &Hidayati, M. (2021). Analysis of Equipment Filling Input and Exit Summary of Covid-19 Insulation Room Care at X Hospital in Bandung. Cerdika: Indonesian Scientific Journal, 1(8). Https://Doi.Org/10.36418/Cerdika.V1i8.143

Handayuni, L. (2020). Medical Records in Health Information Management. In Medical Records in Health Information Management. (Vol. 5, Issue 3).

Harrison, L., & White, S. (2019). Clinical documentation and its importance in healthcare. Journal of Medical Records, 12(1), 34-40.

Hasmah, H., Musfirah, M., & Syamsiana, S. (2022). Managing Medical Records Patient Hospitalization Bangsal Mawar Di Rsup Dr. Tadjuddin Chalid Makassar. J-Kesmas: Public Health Journal, 8(1). Https://Doi.Org/10.35329/Jkesmas.V8i1.2889

Hompson, H., & Peterson, A. (2020). Medical records and regulatory compliance in healthcare facilities. International Journal of Healthcare Management, 28(1), 23-29.

Jones, D., Brown, T., & Miller, K. (2020). The importance of confidentiality in patient care and legal consequences of breaches. International Journal of Medical Ethics, 18(3), 98-104.

Menteri Kesehatan Ri No. 269/Menkes/Per/Iii/. (2008). , About Medical Records. (Jakarta :Depkes Ri. 2008). Fakultas Hukum UNPAS.

Nurliani, A., &Masturoh, I. (2017). Quantitative Analysis Completion Documents Medical Records Hospitals Forms Summary Entry and Exit Tri-month Period IV Year 2015. Journal of the Indonesian House of Representatives, 4(12).

Pujilestari, I., Rohmayani, D., & Monica, R. D. (2023). A Healthy Lifestyle Design for Strong Souls. Puan Indonesia, 4(2). Https://Doi.Org/10.37296/Jpi.V4i2.125

Smith, J., & Johnson, R. (2018). Legal and ethical aspects of medical record handling. Health Law Review, 23(4), 78-85.

Syahputra Wiguna, A., & Soraya Matondang, S. (2019). Analysis Design Form Summary Entry and Exit of Hospitals Patients at Madani Field General Hospital in 2018. Imelda's Recording Scientific Journal and Health Information (Jipiki), 3(1). Https://Doi.Org/10.52943/Jipiki.V3i1.56

Downloads

Published

2024-06-29

How to Cite

Yulfa Yulia, Dian Sari, Oktamianiza, Mila Sari, Vitratul Ilahi, Kalasta Ayunda, & Gopinda Deska Putra. (2024). Overview of Incompleteness of Filling out Summary Forms of in and Outpatient Medical Records on Hypertension in RSUD Lubuk Basung. Miracle Get Journal, 1(2), 22–30. https://doi.org/10.69855/mgj.v1i2.37

Issue

Section

Articles