Analysis Of The Completeness Of Filling In Patient Identity On The Entry And Exit Form For Inpatient Inpatients Of Wangaya Hospital

Ristu Airul Nuralim; Ika Setya Purwanti; I Made Sudarma Adiputra

doi:10.35910/jbkm.v9i1.804

Ristu Airul Nuralim STIKES Wira Medika Bali
Ika Setya Purwanti STIKES Wira Medika Bali
I Made Sudarma Adiputra STIKES Wira Medika Bali

DOI: https://doi.org/10.35910/jbkm.v9i1.804

Keywords: Patient identity, Entry and exit summary form

Abstract

Background: Incompleteness in filling out medical record files will result in the records contained being out of sync and the patient's previous health information being difficult to identify. This study aims to determine the completeness of filling in the patient's identity on the inpatient admission and discharge form.

Method: The research method used is quantitative descriptive. The sample used was 237 medical records of inpatients in October taken by simple random sampling.

Results: The research results showed that 152 sheets of the entry and exit summary forms were complete (64.14%) and 85 sheets of the entry and exit summary forms were incomplete (35.86%). The reason for the incomplete filling in of the patient's identity on the admission and discharge summary form is because the implementation of standard operational procedures has not been optimal. What the hospital needs to do next is carry out outreach regarding filling in patient identity and immediately implement electronic medical records.

Conclusion: There are still incompleteness in filling in the medical resume for the identity of inpatients at Wangaya Hospital.