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    Rekam Medis RSUP
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    This document analyzes the completeness of medical records for 56 patient files from a hospital. It evaluates the presence and completeness of key identifying information like name, medical record number, and date of birth. It also analyzes whether important documents and notes are present, such as initial examination notes, progress notes, informed consent documentation, and discharge notes. Charts and tables are provided showing the number and percentage of files that contained each type of evaluated information.

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    This document analyzes the completeness of medical records for 56 patient files from a hospital. It evaluates the presence and completeness of key identifying information like name, medical record number, and date of birth. It also analyzes whether important documents and notes are present, such as initial examination notes, progress notes, informed consent documentation, and discharge notes. Charts and tables are provided showing the number and percentage of files that contained each type of evaluated information.

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    © All Rights Reserved
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    3 views5 pages

    UEU Undergraduate 11346 LAMPIRAN - Image.Marked

    Uploaded by

    Rekam Medis RSUP
    This document analyzes the completeness of medical records for 56 patient files from a hospital. It evaluates the presence and completeness of key identifying information like name, medical record number, and date of birth. It also analyzes whether important documents and notes are present, such as initial examination notes, progress notes, informed consent documentation, and discharge notes. Charts and tables are provided showing the number and percentage of files that contained each type of evaluated information.

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    © All Rights Reserved
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    of 5

    Lampiran 1.

    Analisis Kuantitatif Rawat Inap


    Formulir Analisis Kuantitatif Rekam Medis Rawat Inap
    Rumah Sakit Pertamina Jaya
    Ada = 1 Tidak ada = 0 Nama Pelaksana: Tanggal:

    IDENTIFIKASI PASIEN KELENGKAPAN LAPORAN/ FORM YANG PENTING AUTENTIKASI PENULIS CATATAN YANG BAIK

    No No.RM KET
    Tgl. Catatan Bukti Catatan Tdk ada
    Jenis Pengkajian Informed Nama TTD Nama TTD Tdk ada tdk ada
    Nama No.RM Lahir/ Perkemba Pengobatan/Pe Saat Resume bagian
    Kelamin Awal Consent dr, dr. Perawat Perawat coretan tipp- ex
    umur ngan rawatan Pulang Kosong

    1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

    1 041710 1 0 1 0 1 1 1 1 1 1 1 0 0 0 0 1 0

    2 032307 1 1 1 1 1 1 1 1 1 1 1 1 0 1 0 1 0

    3 027301 1 1 1 0 1 1 1 1 1 1 1 1 0 0 0 1 0

    4 135559 1 0 0 1 1 1 1 1 1 1 1 1 0 0 0 0 0

    5 135569 1 1 0 1 1 1 1 1 1 1 0 0 1 1 0 0 0

    6 112672 1 1 1 1 1 1 1 1 0 1 1 1 0 1 0 0 0

    7 123488 1 1 1 0 1 1 1 1 1 1 1 1 0 1 0 0 0

    8 118911 1 1 1 1 1 1 1 1 0 1 0 1 1 1 0 0 0

    9 118547 1 1 1 1 1 1 1 1 1 1 1 1 0 1 0 0 0

    10 082470 1 1 1 1 1 1 1 1 0 1 1 1 0 1 1 1 0

    11 098986 1 1 1 1 1 1 1 1 0 1 1 1 1 0 1 1 0

    12 134281 1 1 1 0 1 1 0 1 1 1 1 1 1 1 0 1 0
    13 104425 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 0

    14 001008 1 1 1 1 1 1 1 1 0 1 1 1 0 1 1 1 0
    15 016596 1 1 1 1 1 1 1 1 1 1 1 1 0 1 0 1 0
    16 030562 1 1 1 0 1 1 1 1 0 1 1 1 1 0 1 0 1
    17 101929 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 0
    18 059553 1 1 1 1 1 1 1 1 0 1 0 1 0 1 0 1 1
    19 064288 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
    20 008069 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1
    21 017243 1 1 1 1 1 1 1 1 0 1 1 1 0 1 0 0 0
    22 008814 1 1 1 1 0 1 1 1 0 1 1 1 0 1 1 0 1
    23 135685 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1
    24 133410 1 1 1 1 1 1 1 1 1 1 1 0 0 1 0 0 1
    25 002148 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 0
    26 135731 1 1 1 1 1 1 1 1 1 1 1 1 0 1 0 0 0
    27 091956 1 1 1 1 1 1 1 1 1 1 1 1 0 1 0 1 0
    28 032984 1 1 1 1 0 1 1 1 1 1 1 0 0 1 1 1 0
    29 135589 1 1 1 1 1 1 1 1 0 1 1 1 1 1 0 0 0
    30 049868 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0
    31 135508 1 0 1 1 0 1 1 1 0 1 0 0 1 0 0 1 0
    32 135540 0 1 1 0 1 1 1 1 1 1 1 1 0 1 1 0 0
    33 064339 1 1 1 0 0 1 1 1 1 1 1 1 1 1 0 1 0
    34 112539 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0
    35 096036 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 0
    36 122930 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 0
    37 007457 1 1 1 1 1 1 1 1 0 1 1 1 0 1 0 1 0
    38 116855 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 0
    39 005557 1 1 1 1 1 0 1 1 1 1 1 1 1 1 0 0 0
    40 106639 1 1 1 1 0 1 0 1 0 1 1 1 1 1 0 1 0
    41 007828 1 1 1 1 1 1 1 1 0 1 1 1 0 1 1 0 0
    42 040982 1 1 1 1 0 1 1 1 0 1 0 1 1 1 0 0 0
    43 051583 1 1 1 1 1 1 1 1 0 1 1 1 0 0 1 1 1
    44 015139 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0
    45 088034 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1
    46 051176 1 1 1 1 0 1 0 1 1 1 1 1 0 1 0 1 1
    47 135497 1 1 1 1 1 1 1 1 1 1 1 0 1 1 0 1 1
    48 085631 0 0 0 0 1 1 1 1 1 1 0 1 0 0 1 0 0
    49 041474 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 1 0
    50 047624 1 1 1 1 0 1 1 1 0 1 1 1 0 0 1 1 0
    51 135563 1 0 0 0 1 1 1 1 1 1 1 1 1 1 0 0 0
    52 004612 1 1 1 1 1 1 1 1 0 1 1 1 0 1 0 0 0
    53 041710 1 1 1 0 1 1 1 1 1 1 0 0 1 1 0 0 0
    54 064423 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0
    55 065836 1 1 1 1 1 1 1 1 0 1 1 1 1 1 0 0 1
    56 00 55 57 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1
    TOTAL 54 51 52 46 47 55 53 56 36 56 48 49 29 46 21 31 13
    Lampiran 1. Analisis Kuantitatif
    REKAPITULASI
    ANALISIS KUANTITATIF REKAM MEDIS
    Jumlah Berkas yang dianalisis : 56
    Tanggal: Bulan :

    NO. KRITERIA ANALISA KELENGKAPAN

    JUMLAH PROSENTASE

    IDENTITAS PASIEN
    1. Nama 54 96%
    2. No.Rekam Medis 51 91%
    3. Tanggal Lahir 52 93%
    4. Jenis Kelamin 46 82%

    Average 51 91%

    KELENGKAPAN LAPORAN/ FORM YANG PENTING


    1. Pengkajian Awal 47 84%
    2. Catatan Perkembangan 55 98%
    3. Informed Consent 53 95%
    4 Bukti Pengobatan/Perawatan 56 100%
    5 Catatan Saat Pulang 36 64%
    6 Resume 56 100%
    Average 50 90%

    AUTENTIKASI PENULIS
    1. Nama Dokter 48 86%
    2. Tandatangan Dokter 49 87%
    3. Nama Perawat 29 52%
    4. Tandatangan perawat 46 82%

    Average 43 77%

    CATATAN YANG BAIK


    1. Tidak ada coretan 21 37%
    2. Tidak ada tipp-ex 31 55%
    3. Tidak ada bagian yang kosong 13 23%

    Average 22 38%

    AVERAGE 41 74%

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