PROSIDING INTERNASIONAL KEPERAWATAN Proceedings of the International Conference on Nursing and Health Sciences, Volume 4 No 1
QUALITATIVE ANALYSIS OF MEDICAL RECORD DOCUMENTS IN INPATIENT PATIENTS IN THE PUBLIC HEALTH CENTER
Dublin Core
Title
PROSIDING INTERNASIONAL KEPERAWATAN Proceedings of the International Conference on Nursing and Health Sciences, Volume 4 No 1
QUALITATIVE ANALYSIS OF MEDICAL RECORD DOCUMENTS IN INPATIENT PATIENTS IN THE PUBLIC HEALTH CENTER
QUALITATIVE ANALYSIS OF MEDICAL RECORD DOCUMENTS IN INPATIENT PATIENTS IN THE PUBLIC HEALTH CENTER
Subject
compensation; completeness; consistency; diagnosis, informed consent; recording
Description
The community health center is one of the first level health service facilities that is required to maintain
medical records. Medical record is a document that contains patient identity data, examinations, treatment,
actions, and other services that have been given to patients. Based on the Regulation of the Minister of
Health of the Republic of Indonesia Number 24 of 2022 concerning medical records, Article 18 states that
medical records are analyzed quantitatively and qualitatively. Qualitative analysis aims to ensure complete
and accurate medical record data. Objective: The research objective was to determine the completeness and
consistency of medical records based on six reviews. Method: This type of research is descriptive research
with a retrospective approach. The population is 432 inpatient medical record documents, sample 81
inpatient medical record documents using simple random sampling technique. Collecting data using
interviews and observation. Data processing, data presentation and data analysis were carried out on
quantitative data and qualitative data in a non-statistical or descriptive manner in tabular and textular forms.
Results: The results of the study: 1) review of the completeness and consistency of diagnosis by 71 (88%),
2) review of the consistency of recording diagnoses by 80 (99%), 3) review of things done during care and
treatment by 81 (100%), 4 ) review of 8 forms of informed consent by 8 (100%), 5) review of recording
techniques by 71 (88%), and 6) review of potential compensation matters by 66 (81%). Conclusions: The
results of a qualitative analysis of medical record documents based on the six highest reviews were on the
review of recording things that were done during care and treatment as well as the review of complete
informed consent, namely 81 (100%), while the lowest review was on the review of things that had the
potential for compensation, namely 66 (81 %). The researcher's suggestion to improve the completeness and
consistency is to increase the commitment of Caring Professionals (doctors, midwives, nurses, medical
recorders) regarding the importance of the completeness and consistency of medical records and the
implementation of comprehensive and continuous quantitative and qualitative analyzes.
medical records. Medical record is a document that contains patient identity data, examinations, treatment,
actions, and other services that have been given to patients. Based on the Regulation of the Minister of
Health of the Republic of Indonesia Number 24 of 2022 concerning medical records, Article 18 states that
medical records are analyzed quantitatively and qualitatively. Qualitative analysis aims to ensure complete
and accurate medical record data. Objective: The research objective was to determine the completeness and
consistency of medical records based on six reviews. Method: This type of research is descriptive research
with a retrospective approach. The population is 432 inpatient medical record documents, sample 81
inpatient medical record documents using simple random sampling technique. Collecting data using
interviews and observation. Data processing, data presentation and data analysis were carried out on
quantitative data and qualitative data in a non-statistical or descriptive manner in tabular and textular forms.
Results: The results of the study: 1) review of the completeness and consistency of diagnosis by 71 (88%),
2) review of the consistency of recording diagnoses by 80 (99%), 3) review of things done during care and
treatment by 81 (100%), 4 ) review of 8 forms of informed consent by 8 (100%), 5) review of recording
techniques by 71 (88%), and 6) review of potential compensation matters by 66 (81%). Conclusions: The
results of a qualitative analysis of medical record documents based on the six highest reviews were on the
review of recording things that were done during care and treatment as well as the review of complete
informed consent, namely 81 (100%), while the lowest review was on the review of things that had the
potential for compensation, namely 66 (81 %). The researcher's suggestion to improve the completeness and
consistency is to increase the commitment of Caring Professionals (doctors, midwives, nurses, medical
recorders) regarding the importance of the completeness and consistency of medical records and the
implementation of comprehensive and continuous quantitative and qualitative analyzes.
Creator
Sri Wahyuningsih Nugraheni, Satinder Kumar, Laila Rizky Azizah
Source
http://jurnal.globalhealthsciencegroup.com/index.php/PICNHS
Publisher
Global Health Science Group
Date
January - June 2023
Contributor
peri irawan
Format
pdf
Language
englis
Type
text
Files
Citation
Sri Wahyuningsih Nugraheni, Satinder Kumar, Laila Rizky Azizah, “PROSIDING INTERNASIONAL KEPERAWATAN Proceedings of the International Conference on Nursing and Health Sciences, Volume 4 No 1
QUALITATIVE ANALYSIS OF MEDICAL RECORD DOCUMENTS IN INPATIENT PATIENTS IN THE PUBLIC HEALTH CENTER,” Repository Horizon University Indonesia, accessed February 3, 2025, https://repository.horizon.ac.id/items/show/2786.
QUALITATIVE ANALYSIS OF MEDICAL RECORD DOCUMENTS IN INPATIENT PATIENTS IN THE PUBLIC HEALTH CENTER,” Repository Horizon University Indonesia, accessed February 3, 2025, https://repository.horizon.ac.id/items/show/2786.