GROUP

MEMBERS OF GROUP :

ADHEA RYANAR DWIRISMA

ALIFIA DENOK WIJAYANTI
DEA ARUNGSEA
EKA NUR MAULIDIAH
 THE IMPORTANCE OF COMPLETENESS OF DATA FULFILMENT ON MEDICAL RECORDS

The hospital is part of the continuation of the embodiment of the improvement of health status. In order to realize the optimal
health status, it is necessary to have patient satisfaction which is in accordance with the code of ethics and standard of professional
service that has been established. In the health service activities, it is related to the recording of medical data of patients by doctors or
dentists or other health workers who provide direct health services to patients. Legal aspects of medical records poured in the Law of the
Republic of Indonesia no. 29 years 2004 health personnel are the personnel responsible for filling the medical record is a general
practitioner or specialist dentist or dentist specialist; as well as other health personnel who participate in providing health services
directly to patients.To improve health service in hospital hence need of supporting facility one of supporting facilities that is part of
medical record. In Pelni Petamburan Hospital, the incompleteness of filling out the operation report form was not completed in the
operational report, such as: the name of the anesthesia, the preoperative diagnosis of the operation date and the finished hour, so that the
information is incomplete and accurate. The purpose of this study is to determine the completeness of medical records operating
statement form. The type of research used is a descriptive study in which the authors examine to gain a clearer picture of the accuracy
and accuracy of information provided by the hospital to interested parties. From the result of quantitative analysis of the research on the
filling of operation action report with sample 90 it is concluded that the incompleteness get the description of the completeness of the
data of the highest operational action report (100%), that is: Patient Name, operator While the data has the lowest percentage of
completeness of filling operation (0%), that is: Drugs during surgery, operation hour finish and filling in incomplete surgery report: 8
(8.88%) Abuse doctor not filled 9 (10%) Assisted anesthesia not filled, 27 (30%) Anesthesia method not filled, 38 (42,2%) filling
postoperative diagnose not filled, 24 (22.2%) charging start operation is not filled, 46 (1.11%) charging hours completed operation not
filled. The conclusion of human factor is the most influential on the occurrence of the incompleteness of the medical record, then the
importance of disciplinary enforcement for doctors and medical personnel concerned for more disciplined in the filing of medical record
files as reference Department of health.
 NOMINAL SENTENCES
 The hospital is part of the continuation of the embodiment of the improvement of health status.
( Rumah Sakit merupakan bagian dari kelanjutan perwujudan dari peningkatan derajat kesehatan. )

 Legal aspects of medical records poured in the Law of the Republic of Indonesia no. 29 years 2004 health
personnel are the personnel responsible for filling the medical record is a general practitioner or specialist
dentist or dentist specialist; as well as other health personnel who participate in providing health services
directly to patients.
( Aspek Hukum Rekam Medis tertuang dalam UU Republik Indonesia no. 29 tahun 2004 tenaga kesehatan
adalah tenaga yang bertanggungjawab dalam mengisi rekam medis adalah dokter umum, spesialis dokter
gigi, atau dokter gigi spesialis; serta tenaga kesehatan lain yang ikut memberikan pelayanan kesehatan secara
langsung kepada pasien.)

 To improve health service in hospital hence need of supporting facility, one of supporting facilities that is part
of medical record.
( Untuk meningkatkan pelayanan kesehatan di rumah sakit makan dibutuhkannya sarana penunjang, salah
satu sarana penunjang yaitu adanya bagian rekam medis. )

 The purpose of this study is to determine the completeness of medical records operating statement form.
( Tujuan penelitian ini adalah untuk mengetahui kelengkapan rekam medis formulir laporan operasi.)
 NOMINAL SENTENCES

 The type of research used is a descriptive study in which the authors examine to gain a clearer picture of the
accuracy and accuracy of information provided by the hospital to interested parties.
( Jenis penelitian yang digunakan adalah penelitian deskriptif dimana penulis meneliti untuk memperoleh
gambaran lebih jelas tentang ketepatan dan keakuratan penginformasian yang diberikan pihak rumah sakit
kepada pihak-pihak yang berkepentingan. )

 The conclusion of human factor is the most influential on the occurrence of the incompleteness of the medical
record, then the importance of disciplinary enforcement for doctors and medical personnel concerned for more
disciplined in the filing of medical record files as reference Department of health.
( Kesimpulannya faktor manusia adalah hal yang paling berpengaruh atas terjadinya ketidaklengkapan rekam
medis maka pentingnya penegakan disiplin bagi dokter, dan tenaga medis yang bersangkutan agar lebih
disiplin dalam pengisian berkas rekam medis sesuai acuan departemen kesehatan. )
 VERBAL SENTENCES

 In order to realize the optimal health status, it is necessary to have patient satisfaction which is in accordance
with the code of ethics and standard of professional service that has been established.
( Dalam rangka mewujudkan derajat kesehatan yang optimal perlu adanya kepuaan pasien yang
penyelenggaranya sesuai dengan kode etik dan standar pelayanan pofesi yang telah ditetapkan. )

 In the health service activities, it is related to the recording of medical data of patients by doctors or dentists
or other health workers who provide direct health services to patients.
( Di dalam kegiatan pelayanan kesehatan, sangat berkaitan dengan pencatatan data medis pasien oleh dokter
atau dokter gigi atau tenaga kesehatan lain yang memberikan pelayanan kesehatan langsung kepada pasien.
)
 In Pelni Petamburan Hospital, the incompleteness of filling out the operation report form was not completed
in the operational report, such as: the name of the anesthesia, the preoperative diagnosis of the operation date
and the finished hour, so that the information is incomplete and accurate.
( Di Rumah Sakit Pelni Pertamburan ditemukan adanya ketidaklengkapan pengisian formulir laporan
operasi, ketidaklengkapan tersebut dalam pengisian laporan operasi antara lain : nama anastesi, diagnose
setelah operasi, tanggal operasi, dan jam operasi selesai, sehingga informasi yang dikeluarkan kurang
lengkap dan akurat. )
 VERBAL SENTENCES

 From the result of quantitative analysis of the research on the filling of operation action report with sample 90
it is concluded that the incompleteness get the description of the completeness of the data of the highest
operational action report (100%), that is: Patient Name, operator, while the data has the lowest percentage of
completeness of filling operation (0%), that is: Drugs during surgery, operation hour finish and filling in
incomplete surgery report: 8 (8.88%) , doctor anesthesia not filled 9 (10%), assisted anesthesia not filled 27
(30%), anesthesia method not filled 38 (42,2%), filling postoperative diagnose not filled 24 (22.2%), charging
start operation is not filled 46 (1.11%), charging hours completed operation not filled.

( Dari hasil Analisa kuantitatif, penelitian terhadap pengisian laporan tindakan operasi dengan sampel 90
dikumpulkan bahwa ketidaklengkapan mendapatkan gambaran kelengkapan data pengisian laporan tindakan
operasi yang paling tinggi (100%) yaitu : Nama pasien, operator, sedangkan data yang memiliki persentase
paling rendah kelengkapan pengisian laporan operasi (0%) yaitu : Obat-obatan selama operasi, jam operasi
selesai dan pengisian laporan operasi kurang lengkap yaitu: 8 (8,88%), Dokter anastesi tidak diisi 9 (10%),
asisten anastesi tidak diisi 27 (30%), metode anastesi tidak diisi 38 (42,2%), pengisian diagnose setelah
operasi tidak diisi 24 (22.2%), pengisian jam operasi dimulai tidak diisi 46 ( 1,11%), pengisisan jam operasi
selesai tidak diisi. )
Medical Records and Health Information Technicians - What They Do
Medical records and health information technicians assemble patients' health information including medical history,
symptoms, examination results, diagnostic tests, treatment methods, and all other healthcare provider services.
Technicians organize and manage health information data by ensuring its quality, accuracy, accessibility, and security.
They regularly communicate with physicians and other healthcare professionals to clarify diagnoses or to obtain
additional information.
The increasing use of electronic health records (EHR) will continue to broaden and alter the job responsibilities of
health information technicians. For example, with the use of EHRs, technicians must be familiar with EHR computer
software, maintaining EHR security, and analyzing electronic data to improve healthcare information. Health
information technicians use EHR software to maintain data on patient safety, patterns of disease, and disease
treatment and outcome. Technicians also may assist with improving EHR software usability and may contribute to the
development and maintenance of health information networks.
Medical records and health information technicians' duties vary with the size of the facility where they work.
Technicians can specialize in many aspects of health information.
Some medical records and health information technicians specialize in codifying patients' medical information for
reimbursement purposes. Technicians who specialize in coding are called medical coders or coding specialists. Medical
coders assign a code to each diagnosis and procedure by using classification systems software. The classification
system determines the amount for which healthcare providers will be reimbursed if the patient is covered by
Medicare, Medicaid, or other insurance programs using the system. Coders may use several coding systems,
such as those required for ambulatory settings, physician offices, or long-term care.
 Complex Sentence

The classification system determines the amount for which healthcare providers will be reimbursed if
the patient is covered by Medicare, Medicaid, or other insurance programs using the system.
(Sistem klasifikasi menentukan jumlah penyedia layanan kesehatan yang akan diganti jika pasien dilindungi oleh
Medicare, Medicaid, atau program asuransi lain yang menggunakan sistem)

Independent Clause : (main clause)

The classification system determines the amount for which healthcare providers will be reimbursed

Dependent Clause :
The classification system determines the amount for which healthcare providers will be reimbursed

Past Participle
If the patient is covered by Medicare, Medicaid, or other insurance programs using the system, the
classification system determines the amount for which healthcare providers will be reimbursed
(jika pasien dilindungi oleh Medicare, Medicaid, atau program asuransi lain yang menggunakan
sistem, Sistem klasifikasi ditentukan jumlah penyedia layanan kesehatan yang akan diganti )