Audit Analysis of Medical Records of Patients with Diabetes Mellitus, Gastro Enteritis, and Pneumonia at Bhayangkara Pusdik Shabara Hospital Porong
Analisis Audit Rekam Medis Pasien Diabetes Mellitus, Gastro Enteritis, dan Pneumonia di Rumah Sakit Bhayangkara Pusdik Shabara Porong
DOI:
https://doi.org/10.21070/ups.3758Keywords:
Hospital, Hospital Accreditation, Medical Record AuditAbstract
A hospital is an institution that operates in the field of comprehensive health services, starting from inpatient, outpatient and emergency services. One effort to improve health services is the completeness of medical record documents so that patient medical records need to be audited to support the hospital's accreditation. The data analysis used is quantitative analysis for . Observations were carried out from October 2021 to October 2022. The data taken were inpatient medical record documents including 34 medical record documents for patients diagnosed with Diabetes Mellitus, 25 medical record documents for Gastro Enteritis patients, and 17 medical record documents for Pneumonia patients. The research results showed that the completeness of the review of patient social data was 23.7%, the review of patient record evidence was 30.3%, the review of the validity of patient records was 67.1%, and the review of patient recording procedures was 56.6%.
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