| dc.contributor.author | ULFA, MH MUFLIHATUL | |
| dc.contributor.author | SUNDARI, SRI | |
| dc.contributor.author | LISTIOWATI, EKORINI | |
| dc.date.accessioned | 2017-09-08T04:30:04Z | |
| dc.date.available | 2017-09-08T04:30:04Z | |
| dc.date.issued | 2017-09-06 | |
| dc.identifier.issn | [ISSN 2250-3153] | |
| dc.identifier.uri | http://repository.umy.ac.id/handle/123456789/14403 | |
| dc.description | Hospitals are health care institutions that provide full-scale personal health services that provide inpatient, outpatient, and
emergency care services. Each Hospital has the obligation to provide safe, quality, anti-discrimination and effective health serv
ices by prioritizing the interests of the patient in accordance with hospital service standards; create, implement and maintain health care quality standards in hospitals as a reference in serving patients and organizing medical records [1].
As an effort to improve the quality of Hospital service, it is obliged to make periodic accreditation at least 3 (three) years [2].
The implementation of accreditation based on KARS 2012 standard includes several stages of preparation of accreditation, accreditation guidance, accreditation implementation and post accreditation activities [3]. The implementation of the KARS (Komisi Akreditasi Rumah Sakit) accreditation survey includes steps such as the individual patient search and the patient's medical record of being closed (the patient has returned). This study was conducted to ensure hospital compliance provides track records of medical records [4]. A medical record is a file containing records and documents about the patient's identity, examinations, medications, actions and other services that have been provided to the patient [5]. In the medical aspects, medical records are used as a basic for planning care provided to a patient and in order to maintain and improve the quality of care through medical audits, clinical risk management and patient safety [6]. Mentioned by David Karp et all (2008) [7] that good documentation will protect the patient. So, good documentation in medical record is an important aspect in realizing patient safety. The completeness of medical records is very
important in the implementation of health services, especially to improve the quality of patient care and safety.
Muhammadiyah Hospital of Ponorogo (RSUM Ponorogo) is a type C hospital in Ponorogo. This hospital has followed KARS
2012 standard accreditation and has been declared a plenary pass based on a decree dated August 23, 2016 [8]. A preliminary study conducted by researchers in January 2017, of the 10 files studied did not find complete files as a whole
according to the standards set by KARS 2012. Among them is the standard of PFR 6.4 only reached 18.5%, standard ASC 7.1reached 22.2%, ASC 6 standard was achieved at 55.5% and several other standards. Although the status of accreditation plenary has been achieved by RSUM Ponorogo, but efforts to maintain service quality improvement and patient safety should still be done. Seeing the importance of medical records documentation especially for patient safety and to maintain the quality of service and there are still some improvement suggestions from the medical record
-related accreditation team and the finding of incomplete medical record in the months after the accreditation, it is necessary to evaluate the completeness of medical record based on KARS standard 2012 at RSUM Ponorogo
. | en_US |
| dc.description.abstract | The completeness of medical records is very important in the provision of health services, especially to improve the quality
of service and patient safety. As an effort to improve the quality of service Muhammadiyah Hospital of Ponorogo has followed the KARS 2012 accreditation with a plenary achievement in August 2016. Although the status of accreditation plenary has been achieved but efforts to maintain improvements in patient care and patient safety should still be done. This study aims to determine the description of medical record completeness at Muhammadiyah Hospital of Ponorogo. This research is an observational analytic, quantitative approach with cross sectional design. Data analysis using univariate and bivariate analysis with Chi Square test. In the sample prior to the accreditation survey, the standard that was not achieved was PFE (Patient and Family Education) 2.1, while for
samples after the accreditation survey, the unreachable standards were PFE 2.1, MCI (Management of Communication and Information) 19.3 and ACC (Acces to Care and Continuity of Care) 3.2.1. There are some standards that have statistically significant differences in the completeness of the medical record between before the accreditation survey and after the accreditation survey ie PFR (Patient and Family Right) 6.4 (p = 0.001), ASC (Anasthesia and Surgical Care) 7.1 (p = 0.018),AOP (Assesment of Patient) ( 1.6 (p = 0.020) , ASC 7.4 (p = 0.005), MCI 19.3 (P = 0.001). | en_US |
| dc.language.iso | en | en_US |
| dc.publisher | INTERNATIONAL JOURNAL OF SCIENTIFIC AND RESEACH PUBLICATION | en_US |
| dc.relation.ispartofseries | IJSRP, Volume 7, Issue 9, September 2017 Edition [ISSN 2250-3153]; | |
| dc.subject | Medical record completeness, KARS (KomisiAkreditasiRumahSakit) 2012 standard | en_US |
| dc.title | EVALUATION OF MEDICAL RECORD COMPLETENESS BASED ON KARS STANDARD 2012 AT MUHAMMADIYAH HOSPITAL OF PONOROGO INDONESIA | en_US |
| dc.type | Other | en_US |
