COMPLETENESS OF FILLING OUT THE DISCHARGE SUMMARY SHEET FOR HOSPITALIZATION AT THE TK.III DR.SOETARTO (DKT) HOSPITAL

Abstract

The completeness of the contents of the notes or documents on the discharge summary sheet contains
all the very important clinical information related to the patient's identity and diagnosis. As part of
improving the quality of service, hospital performance must regularly assess the contents and
completeness of medical record files, especially on the discharge summary sheet listed in SNARS Issue
1 in MIRM 15. The purpose of this study was to determine the assessment of the filling score and the
completeness of filling in the inpatient medical record file on the discharge summary sheet based on
SNARS Edition 1 in kindergarten hospitals. III Dr.Soetarto (DKT). This type of research is a quantitative
descriptive study using a cross-sectional design. With variable analysis of the completeness of the
inpatient medical record file on the discharge summary sheet and data analysis using Ms. Excel for
Windows. The results of the study were the completeness of filling in the inpatient medical record file
on the discharge summary sheet as many as 30 inpatient medical record files on the discharge summary
sheet only 33.33%. Based on the regulations, the completeness of SNARS Edition 1 on EP 1 components
is fully filled, in EP 2 components partially filled, in EP 3 components partially filled, in EP 4
components fully filled, in EP 5 components fully filled, in EP 6 components fully filled. Conclusion of
this study The assessment of the filling score on theinpatient medical record file on the discharge
summary sheet is classified as insufficient because it is only partially filled. The completeness of filling
out the inpatient medical record file on the discharge summary sheet is classified as incomplete so that
it is not in accordance with the standards in SNARS Edition 1.