Faktor-faktor yang memengaruhi kelengkapan rekam medis rawat inap di rumah sakit: literature review: Factors affecting the completeness of hospitalizationmedical records: a literature review

Medical record is a document that contains patient data consisting of identity, history of examination and treatment of patients. Medical records must be filled out completely because they can be used as a legal basis if something unexpected happens during a health action. Completeness of medical records can be used as a support to improve health services. Based on the results of previous studies, it was found that only 74% of the completeness of the RM from the name of the action indicator. This literature review aims to determine the factors that affect the completeness of filling out medical records. Methods: The method used in this article is a literature review, the search for articles in this LR uses a google scolar, with the keywords "completeness factors", AND "medical records" AND "hospitalization". The articles found in the search were 262 articles, then re-evaluated according to the inclusion and exclusion criteria that had been set so that finally 5 articles were available that could be reviewed. Results: Factors that affect the completeness of filling out medical records are man, method, material, money Man, money and methode are factors which effect uncomplitement of medical records, so that recommended to make standard operating procedure (SPO) in doing medical records then for giving motivation to the health worker in filling medical records we can giving present and clear sanctions for them. Conclusion: Man, money, materials, and methods are factors that can affect the incompleteness of medical records, so it is recommended to make Standard Operating Procedures (SOP) in carrying out medical record activities and socialize them on an ongoing basis, then to motivate health workers in filling out RMs, prizes can be given and clear sanctions.Rekam medis adalah dokumen yang berisi data pasien yang terdiri dari identitas, riwayat pemeriksaan dan pengobatan pasien. Rekam medis harus diisi dengan lengkap karena dapat digunakan sebagai landasan hukum jika terjadi hal-hal yang tidak diharapkan selama suatu tindakan kesehatan. Kelengkapan rekam medis dapat dijadikan sebagai penunjang untuk meningkatkan pelayanan kesehatan. Berdasarkan hasil penelitian sebelumnya, ditemukan hanya 74% kelengkapan RM dari nama indikator tindakan. Tinjauan pustaka ini bertujuan untuk mengetahui faktor-faktor yang mempengaruhi kelengkapan pengisian rekam medis. Metode : Metode yang digunakan dalam artikel ini adalah literature review, pencarian artikel di LR ini menggunakan google scolar, dengan kata kunci “faktor kelengkapan”, DAN “rekam medis” DAN “rawat inap”. Artikel yang ditemukan dalam pencarian sebanyak 262 artikel, kemudian dievaluasi kembali sesuai dengan kriteria inklusi dan eksklusi yang telah ditetapkan sehingga akhirnya tersedia 5 artikel yang dapat direview. Hasil : Faktor-faktor yang mempengaruhi kelengkapan pengisian rekam medis adalah manusia, metode, bahan, uang Man, uang dan metode merupakan faktor-faktor yang mempengaruhi tidak lengkapnya rekam medis, sehingga disarankan untuk membuat standar operasional prosedur (SPO) dalam melakukan rekam medis kemudian atas pemberian motivasi kepada tenaga kesehatan dalam pengisian rekam medis dapat kami berikan sanksi yang tegas dan jelas bagi mereka.Kesimpulan: Man, money, material, dan methode merupakan faktor-faktor yang dapat memengaruhi ketidaklengkapan medis, sehingga disarankan untuk membuat Standar Prosedur Operasional (SPO) dalam melakukan kegiatan medis dan disosialisasikan secara bertahap, kemudian untuk memotivasi petugas dalam pengisian RM bisa diberikan hadiah dan sanksi yang jelas. Medical record is a document that contains patient data consisting of identity, history of examination and treatment of patients. Medical records must be filled out completely because they can be used as a legal basis if something unexpected happens during a health action. Completeness of medical records can be used as support to improve health services. Based on the results of previous studies, it was found that only 74% of the completeness of the RM from the name of the action indicator. This literature review aims to determine the factors that affect the completeness of filling out medical records. Methods: The method used in this article is a literature review, the search for articles in this LR uses a google scholar, with the keywords "completeness factors", AND "medical records" AND "hospitalization". The articles found in the search were 262 articles, then re-evaluated according to the inclusion and exclusion criteria that had been set so that finally 5 articles were available that could be reviewed. Results showed that factors affecting the completeness of filling out medical records are man, method, material, and money. They affected uncomplitement of medical records, so it’s recommended to make standard operating procedures (SPO) in doing medical records and giving motivation to the health worker in filling medical records. We can give presents and clear sanctions for them. It is recommended to make Standard Operating Procedures (SOP) in carrying out medical record activities and socialize them on an ongoing basis, then to motivate health workers in filling out RMs, prizes can be given and clear sanctions