EVALUASI IMPLEMENTASI REKAM MEDIS TERINTEGRASI DI INSTALASI RAWAT INAP RSUP Dr SARDJITO YOGYAKARTA
| Main Authors: | , Patricia Suti Lasmani, , Dr. Fitri Haryanti, SKp., M.Kes |
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| Format: | Thesis NonPeerReviewed |
| Terbitan: |
[Yogyakarta] : Universitas Gadjah Mada
, 2013
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| Subjects: | |
| Online Access: |
https://repository.ugm.ac.id/126942/ http://etd.ugm.ac.id/index.php?mod=penelitian_detail&sub=PenelitianDetail&act=view&typ=html&buku_id=67181 |
Daftar Isi:
- Background : The result of interview sub-committee forensic medical officer who claimed that 100 % patients medical records requiring a visum and a medical certificate is not complete. The patients progress note are still on fragmented segment so less reflects the collaboration. Sardjito Hospital has implemented an integrated medical record, therefore, it is needed an evaluation of the integrated medical record implementation Objective: To evaluate the implementation of inpatient integrated medical records consist of completeness, patient-centered, inter-professional collaboration and confidentiality aspects, and to find out the reasons of incompleteness data, benefits, barriers, and integrated medical records implementation. Methods: It is a case study with a descriptive explanatory for the implementation of an integrated medical record. Sources of evidence used to documentation of medical records with patients had been treated at least 3 days in 6 wards to get the data completeness of the medical record as quantitative data, then the results do triangulation by observation and focus group discussions as qualitative data. Results: The result still need to be improved, clarity: the 29.7 % correction results with crossed out and initialed and none medical records using standard abbreviations