Analisa Kuantitatif Dokumen Rekam Medis Pasien Rawat Inap pada Bangsal Anggrek di RSUD Kota Salatiga pada Tahun 2016

Documents inpatient medical records can be used to improve the quality of health services in the hospital. In order to document medical records can be sustainable then charging document in the medical record must be filled with full selengkap- and also serve as legal evidence apabiladibutuhkan. From the observation of each ward, ward Orchid highest percentage, based on the fourth review conducted on the document file medical records found on the review of identification, review of reporting, review records and review authentication. Documents incomplete medical records can lead to medical information is not continuous and document medical records can not be used as legal evidence in case of legal malpractice.To obtain the medical record number data is collected and processed in editing, tabulation and calculation, then analyzed descriptively. This type of research is descriptive method and cross sectional observation, tabulation is taken from medical records document inpatient wards orchid, while the samples used by accidental sampling method.The results of this study concluded that the percentage of incompleteness of 4 review is quite high. Incompleteness highest level on a review of records. Thus, the researchers recommend that there should be a quantitative analysis of the level of completeness of medical record document