Management of medical record in installation of inpatient Regional Public Hospital Batara Guru Belopa

Abstract

Objective

This study aims to obtain information about the management of the patient's medical record completeness in the inpatient installation of Regional Public Hospital Batara Guru Belopa.

Methods

Research method is qualitative using phenomenology approach. Determination of informants using purposive sampling method (18 informants). Data analysis using emik data reduction.

Result

Human Resources who still need additional staff because large number of patients and workload of the officers, doctors rarely fill in the full medical record sheets due to negligence of doctors due to other activities. Procedure, there are still officers who do not know the flow of exit and entry of the medical record file to the inpatient installation. Medical record completeness is seen from the information, implementation of hospital policy regarding the completeness of filling in medical record is not maximal.

Conclusion

Hospital should be conducted a routine evaluation related to the completeness of the medical record and activated hospital Management Information System.