- FAKTOR FAKTOR PENYEBAB KETIDAKLENGKAPAN PENGISIAN JENIS DAN KODE TINDAKAN PADA LEMBAR RAWAT INAP DI RS PKU MUHAMMADIYAH YOGYAKARTA UNIT II

• Main Authors: , ALETHEA ISFAHANIE, , Nuryati, S.Far., MPH
• Format: Theses and Dissertations NonPeerReviewed
• Published: [Yogyakarta] : Universitas Gadjah Mada 2014
• Subjects: ETD
• Online Access: https://repository.ugm.ac.id/122215/; http://etd.ugm.ac.id/index.php?mod=penelitian_detail&sub=PenelitianDetail&act=view&typ=html&buku_id=62314
• Institution: Universitas Gadjah Mada

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.