ANALISIS KELENGKAPAN PENGISIAN LAPORAN OPERASI PASIEN BEDAH GUNA MENUNJANG MUTU REKAM MEDIS

This study aims to analyze completeness of the surgical patient report at the hospital X Bandung. The research method is qualitative with a descriptive approach and the data collected by observation, interview with medical records officer, heads of medical records and doctors. The technique of collecting sampel used is Purposive Sampling based on Slovin formula. The object of the study was 80 sample of the surgical report. Based on result : patient review identification 100%, review vital repots 65%, review on authenticity 90%, and long review 78%. with any problems the have: operation loading sheet to be incomplete, the doctor’s writing cant read clearly, doctor’s did not provide important reports. The advice the writer gives to fix the problem, conduct a verification of the operation report sheet, return your surgical report sheet to be equipped by the doctor, give 1x24 hours to complete the operation report shee