Zubir, NIM011328156301 and Hartono Kahar, - (2019) Analysis Of The Difference Of Completeness Of Reporting And Documentation Of Laboratory Critical Values Pre And Post-Intervention In Bona Ward Dr. Soetomo Hospital Surabaya. Indonesian Journal of Clinical Pathology and Medical Laboratory, 26 (1). pp. 23-29. ISSN 2477-4685

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Abstract

Completeness of reporting and documentation of laboratory critical values in medical records is important for patient safety, hospital accreditation, and legality. Preliminary study in the Dr. Soetomo Hospital ward showed that the laboratory critical value report and documentation was 0% complete, 4% incomplete, and 96% undocumented. This was a quasi-experimental study with one group pretest and posttest design. Technical guidance of reporting and documentation of laboratory critical values in medical records and supervision was given to 26 doctors. The results evaluated were doctor's knowledge and attitude towards critical value reporting, completeness of documentation in medical records, and Turnaround Time (TAT). The number of reporting critical values samples was 72 before and after the intervention. The critical value samples were taken by purposive sampling. The data were analyzed using the Mann-Whitney test. There were significant differences in the level of knowledge, doctor's attitudes, and completeness of critical values documentation before and after the intervention. Doctors with good knowledge increased from 3.85% to 92.31%. The attitude to complete critical values documentation improved from 0% to 76%. Completeness of critical values documentation in medical records improved from 100% undocumented to 19.44% undocumented, 11.11% incomplete, and 69.45% complete. There were no significant differences of TAT before and after the intervention, all the TAT was less than 30 minutes and met the TAT requirement. The intervention was able to increase doctor knowledge, attitude, and completeness of the laboratory critical values reporting and documentation in the patient's medical record.

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