Kelengkapan Pengisian Formulir Resume Medis Pasien Rawat Inap di Rumah Sakit Umum Daerah Ambarawa

Medical record is a file contain record and document of patient identity,checkup, medical treatment, actions and other services that have been given topatients. One of the important form that used for medical utility is a patientmedical resume. Incompleteness of medical resume form is still a problem insome hospitals, including Rumah Sakit Umum Daerah Ambarawa. Based onpreliminary research conducted on 2nd April 2016, from 10 medical resume formthat were observed, all forms were not completely filled. The purpose of theresearch is to determine the completeness of the medical resume form based on anidentification review, important report review, authentication review, and recordsreview.Research design used descriptive survey with documentation method.Instrument of the research is checklist. One hundred of medical resume forms areused as samples by using accidental sampling technique. The collected data wereanalyzed descriptively using frequency distribution tables and percentages.The results of the research completeness inpatient medical resume form atRumah Sakit Umum Daerah Ambarawa shows that a complete identificationreview is 38 form (38%), while the completeness at an important report reviewand records review is only 1 form (1%), and the completeness of authenticationreview is 59 form (59%)