DENI, IKRISTIYANTO (2023) TINJAUAN KELENGKAPAN PENGISIAN RINGKASAN PULANG PASIEN RAWAT INAP DI RUMAH SAKIT SETIA MITRA JAKARTA SELATAN. Diploma thesis, AKADEMI PEREKAM MEDIS DAN INFOKES BHUMI HUSADA JAKARTA.

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Abstract

Deni Kristiyanto), Rewiev of Completeness discharge summary of inpatient at Setia Mitra Jakarta Selatan Hospital. Scientific Writing, Jakarta: D-III Program of Medical Records and Health Information, Bhumi Husada Jakarta, 2022. This study was conducted to get an idea of the level of filling out the discharge summary at Setia Mitra Hospital by identifying Standard Operating Procedures (SPO), calculating the number of completeness of filling out the discharge summary and identifying the factors causing the incomplete completion of the discharge summary. The research method used is descriptive quantitative method by obtaining an overview of filling out summary of discharge at Setia Mitra Hospital. Methods of collecting data by observation and interviews. The population in this study were inpatients from October to December 2021 with 584 discharge summaries, sampling using slovin method with an error tolerance of 0.05, namely 237 discharge summaries. The result of this research is Setia Mitra Hospital already has Standard Operating Procedures (SOP). The results of the review quantitative analysis of the discharge summary with a sample of 237 are the 23 complete discharge summaries (9.7%), and 214 discharge summaries (90.3%) incomplete. Factors causing incomplete of discharge summary, among others, SOP is not routinely socialized, no analysis of completeness of discharge summary filling, limited time for doctors due to workload and busy schedule and nurses do not remind DPJP doctors to fill out a summary. References : 21 (1994 – 2022). Keywords : Incompleteness, Discharge Summary, Hospital.

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