Dian Fajar Hapsari (2021) Analisis Faktor Yang Berpengaruh Pada Kelengkapan Pengisian Rekam Medis Manual Dan Elektronik Serta Dampak Ketidaklengkapan Pengisian Rekam Medis (Systematical Review). Thesis thesis, UNIVERSITAS AIRLANGGA.

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Abstract

Medical records are important documents that must be completed because all documentation of services is included in them. The problem that occurs in various health care facilities in several countries is the incomplete filling of medical records, both manual and electronic. This systematic review study aimed to analyze the factors that affect the completeness of filling in manual and electronic medical record files. This research method uses a systematic review research study design. Sources of information data from seven electronic databases (Scopus, CINAHL, Springer, DOAJ, ScienceDirect, PubMed, and Google Scholar). The search strategy uses the PICOS framework technique with keywords and synonyms to identify articles published in 2010 and beyond. This research work reviewed 32 articles that met the eligibility criteria based on the research theme and objectives. This study found that factors affecting the completeness of manual medical records were divided into individual factors, organizational factors, internal factors, and external factors. The impact of incomplete filling in manual and electronic medical forms is due to the incompleteness of the data entered the medical records. In electronic medical records, the filling accuracy is essential; if there is an error in the input of the data, the data obtained will be incorrect and difficult to correct. This research work concludes that the completeness of manual and electronic medical records is influenced by the level of education, employment status, tenure, workload, motivation, responsibility, attitudes, work expectations, knowledge, compliance filling medical records, leadership, supervision, reward and punishment. communication, managerial policies, fulfillment of facilities and infrastructure, form design and content, medical record flow, user friendly medical record display, replacement of old systems with newEDS systems, SPO filling of medical records, completeness of features and information needs for external reporting. The impact of the incompleteness of filling in medical records is the incompleteness of data that will become information.

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