ANALISIS KELENGKAPAN PENULISAN SOAP, KIE, DAN ICD X PADA REKAM MEDIS DI POLI UMUM DAN KIA-KB PUSKESMAS DARUSSALAM MEDAN
HAFIFAH (2023) ANALISIS KELENGKAPAN PENULISAN SOAP, KIE, DAN ICD X PADA REKAM MEDIS DI POLI UMUM DAN KIA-KB PUSKESMAS DARUSSALAM MEDAN , TESIS, UNIVERSITAS PRIMA INDONESIA
ABSTRAK
Health service information systems for individual health efforts consist of clinical information systems, health service administration systems, health service support systems, and health service decision support systems. One of the developments in information technology that is currently increasing rapidly is the health service administration system which consists of a payment information system (billing) and a patient registration information system. The purpose of this study was to analyze the completeness of writing SOAP, KIE and ICD X on medical records at the General Polyclinic and KIA-KB at the Darussalam Health Center in Medan.
This research is a descriptive study with a cross-sectional research design which was carried out at the Darussalam Medan Health Center in June-August 2022. The sample size was determined by the slovin formula, namely 97 people. Data were analyzed using the Chi Square test.
The results showed that there was no increase in filling out SOAP, KIE and ICD X which had been studied for 3 months. Identification Review is a review of data containing patient identity which includes medical record number, patient name, age and gender, patient address which can be identified by examining each sheet of medical record. The medical record file is declared complete if each sheet has the patient's name and medical record number. If there is an anonymous sheet, it must be reviewed to determine whose the sheet belongs. In this case, if the audit is carried out before the patient returns (Concurrent Analysis) it is better because it is faster to find out his identity than if it is done after the patient returns (Retrospective Analysis).
The suggestion in this study is that the results of this research become input for evaluating and training all employees so that there is an increase in writing clinical documentation.
JURNAL
| KATEGORI JURNAL | Jurnal Nasional Terakreditasi |
|---|---|
| TAHUN JURNAL | 2023 |
| VOLUME JURNAL | 5 |
| NOMOR JURNAL | 4 |
| NAMA PENERBIT | CONTAGION SCIENTIFIX PERIODICAL JOURNAL OF PUBLIC HEALTH AND COASTAL HEALTH |
| NOMOR ISSN/ISBN | 26850389 |
| LAMAN PENERBIT (URL) | http://jurnal.uinsu.ac.id/index.php/contagion |
| LAMAN ARTIKEL (URL) | https://jurnal.uinsu.ac.id/index.php/contagion/article/view/16591 |