PERBEDAAN KELENGKAPAN PENGISIAN REKAM MEDIS ANTARA INSTALASI RAWAT JALAN DAN INSTALASI RAWAT DARURAT DI POLI BEDAH RSUP DR. KARIADI SEMARANG

Abstract

Background In the present time, medical records filled by healthcare officers in many hospitals are still in a low number, while medical record filling is an important part of giving a good service towards patient, and the data is needed for the sake of hospital management, patient, and the healthcare officer themselves. On initial survey, there was a difference between medical records in Outpatient Unit and Emergency Unit of RSUP dr. Kariadi Semarang. Aim To understand the differences between medical record comprehensiveness in Surgery Outpatient Unit and Surgery Emergency Unit of RSUP dr. Kariadi Semarang. Method This research was conducted using analytic surveillance with cross sectional study approach. The samples were taken from medical record documents in October 2011, specifically 62 records from Surgery Outpatient Unit and 62 records from Surgery Emergency Unit of RSUP dr. Kariadi Semarang. Results The descriptive analytic study showed the difference between medical records comprehensiveness in Outpatient Unit and Emergency Unit of RSUP dr. Kariadi Semarang. From 62 medical records in Outpatient Unit, the comprehensiveness rate was 58.1% while from 62 medical records in Emergency Unit, the comprehensiveness rate was 32.3%. In Chi-Square test, there was a significant difference between medical record comprehensiveness in Surgery Outpatient Unit and Surgery Emergency Unit of RSUP dr. Kariadi Semarang (p=0.004). Conclusion The medical records comprehensiveness in Surgery Outpatient Unit was higher than those in Surgery Emergency Unit. Keywords outpatient medical record, emergency medical record