FAKTOR-FAKTOR YANG BERHUBUNGAN DENGAN KELENGKAPAN RESUME MEDIS PASIEN RAWAT INAP DI RSUD BATU BARA TAHUN 2021

Abstract

Every hospital is required to maintain medical records. In the medical record there is a medical resume form which is very important to complete, because it contains the entire medical history of the patient. Problems were still found related to filling out incomplete medical resume forms at Batu Bara  General Hospital.The purpose of this study was to determine the factors related to the completeness of inpatients  medical resume at Batu Bara General Hospital. This type of research used an observational research method by using cross sectional design. The total population were 36 doctors who work at Batu Bara General Hospital.The sampling technique used  total sampling. The research instrument was questionnaire and checklist sheet. Data analysis used Chi Square test. The results showed that from 36 doctors, 23 doctors (64%) had knowledge in the good category about filling out medical resume sheets and 13 doctors (36%) had knowledge in the poor category while 27 doctors (75%) had attitudes in the good category. and 9 doctors (25%) had bad attitude.The results of Chi Square test showed that there was significant relationship between doctor's knowledge and the completeness of a medical resume with  P value of (0.003) (P-value <0.05) and  Prevalence Ratio (PR) = 0.081. Meanwhile, the results of the Chi Square test showed that there was a significant relationship between the attitude of doctor and  completeness of  medical resume with P value (0.021) (P-value <0.05) and  Prevalence Ratio (PR) = 0.200. The hospital should provide understanding and socialization to doctors that it is important to complete medical records, especially on medical resume sheets