PENYEBAB KETIDAKTERISIAN DIAGNOSIS PADA LEMBAR RESUME MEDIS PASIEN RAWAT INAP DI RUMAH SAKIT KHUSUS BEDAH ISLAM CAWAS KLATEN

Background: Resume or summary of the history of home is a summary of the entire period of care and treatment of patients as has been attempted by the health workers and other interested parties. This sheet must be signed by the doctor who treated patients (Hatta, 2008). Resume should be written in the patient's home. Resumes should contain a summary of the findings and important events during admission, the state time to go home, and subsequent treatment plan. Medical resumes a sheet that is used as the manufacture of medical certificate for the purposes of third parties such as insurance claims, medical record file when it is time to eradicate the medical resume sheet is still stored and maintained. This is a resume sheet sheet that can be copied by the patient, according to the Minister of Health no. 269 of 2008 Chapter IV Article 12, paragraph 4 is described \"as a summary of the medical records referred to in Section 3 can be given, be noted by the patient or the authorized person or the patient's written consent or the patient's family is entitled to it\". Objective: Knowing the diagnosis unfilled resume sheet rawatt hospitalized medical patients at the Hospital for Special Surgery Islam Cawas Klaten. Special purpose: to find the cause unfilled diagnosis on inpatient medical resume sheet at the Hospital for Special Surgery Islam Cawas Klaten. And the impact of the diagnosis on the sheet unfilled resume inpatient medical at the Hospital for Special Surgery Islam Cawas Klaten. Method: a descriptive study using a qualitative approach to data collection is cross-sectional. The subjects in this study were each a medical records clerk, nurse, doctor. Techniques of data collection by interview, observation, and documentation. Results: Causes unfilled diagnosis on inpatient medical resume sheet at the Hospital for Special Surgery Cawas Klaten Islam there are several factors: human factors: 1.) Doctor: Busy physician at the Hospital for Special Surgery Islam Cawas Klaten. The specialist will visite if no scheduled practice clinic alone, visite performed before a specialist practice in the clinic. while in the clinic patients have been waiting for, that's what makes specialist a hurry and do not write resumes diagnosis pda sheet. 2.) Nurse: the nurse's efforts to alert physicians to fill medical diagnosis on a resume sheet does not produce results and medical record file just stacked. Because it has been rarely reminding the nurses and doctors instantly restore the file medical records to medical records. 3.) The records officer: medical record file back in assembling and just not written in the book of registers and then restored to the filing room. Unfilled impact on sheet resume medical diagnosis is the difficulty in making a medical certificate in because of the diagnosis on a sheet of medical resume is not filled, the official medical record should contact the treating physician to fill the diagnosis and take a longer time in the manufacture of Medical Certificate