Regional-Based Competency Test for Medical Record and Health Information Management Students in Indonesia

Abstract

The evaluation of the contents of the medical record
is one of the authorities carried out by the medical
recorder. Based on a preliminary study of qualitative
medical analysis of 10 medical record documents (DRM)
inpatients of DHF cases in 2015 at RSUD Dr. Soekardjo
showed that most of the medical information recorded
in DRM was still incomplete. The purpose of this study
was to analyze the completeness of the Medical Record
Documents for DHF cases using the Hatta method.
The study was conducted at RSUD dr.Soekardjo in
Tasikmalaya city in May - November 2016. The population
in this study was the average number of DRM hospitalized
DHF cases of 460 documents and the total sample of 214
documents. The design of this research is descriptively
supported by a qualitative approach using in-depth
interviews. The results of the administrative qualitative
analysis indicate that there is already a clear problem in
DHF and has consistently been strengthened by the results
of temperature tests and routine blood laboratory tests.
There is an underlying reason for treatment. The results of
the qualitative medical analysis showed that the diagnosis
of DHF was mostly complete, and extra information as
a follow-up to information about patient complaints
was already available such as the results of physical
examination, an examination of vital signs, and blood
lab tests. Assessment of DHF diagnosis so far is mostly
sufficient with the results of the patient’s history and the
effects of the patient’s platelet levels. It is strengthened by
a serological examination of IgG and IgM, but some of
the data is still there, whose data utilization has not been
extra. Complete recording and utilization of data about
routine checks, treatment, and the complete action are
available on day 1 of the patient being treated. There is
is no description of the patient’s discharge criteria and
follow-up.