ANALYSIS OF COMPLETENESS OF FILLING IN MEDICAL RESUME SHEET IN PATIENTS AT RAJAWALI CITRA GENERAL HOSPITAL YOGYAKARTA

Abstract

Each form on the medical record must be filled out completely according to the Minimum Service
Standard, which is 100%. One of the important forms of medical records is the medical Resume form.
This study aims to determine the percentage of completeness of filling out the medical resume sheet of
inpatients based on 4 components, namely identification, important reports, authentication and correct
documentation at Rajawali Citra Hospital Yogyakarta. This research uses a quantitative descriptive
type of research using a Survey research design. The sampling technique uses Incidental Sampling
with a total sample of 96 sheets of inpatient medical resumes The results of the study conducted using a
quantitative analysis checklist of 96 medical resume sheets of inpatients at Rajawali Citra Hospital
Yogyakarta based on identification obtained a percentage of completeness of 77.4% and a percentage
of incompleteness of 22.6%. The percentage of completeness of important reports is 93% and the
percentage of incompleteness is 7%. The percentage of completeness of authentication was 69.2% and
the percentage of incompleteness was 30.8%. As well as in the correct documentation, the percentage
of true is 93.4% and the percentage of incorrect is 6.6%. The conclusion of this study is that the
percentage of completeness of filling out the medical resume sheet of inpatients based on 4
components, namely identification, important reports, authentication and correct documentation at
Rajawali Citra Yogyakarta Hospital is still below 100%.