Management Completeness Analysis Result of The Pulmonary Tuberculosis 01 (Tuberculosis Patient Treatment Card) at Outpatient Unit of Semarang Public Health Center Year 2019

Abstract

WHO Tuberculosis Report 2016 stated that the
amount of Tuberculosis (TB) case in Indonesia occupies
the second highest ranking in the world. Due to promotive,
preventive and curative treatment services for TB cases,
Public Health Center needs comprehensive medical
records as the reference. In fact, Tuberculosis Patient
Treatment Card (TB 01) at Karangdoro Public Health
Center was incomplete, was found that there’s insufficient
of medical record number, the diagnosis, signature and
the full name of the staff. Besides, TB 01 Documents are
stored separately from other documents at Gayamsari
Public Health Center. Whereas, one of the basis reference
of patient diagnosis is examination support results. So,
this study aims to analyze the comprehensiveness of
Tuberculosis Patient Treatment Card (TB 01) of Semarang
Public Health Center. This study uses observation and
interview methods. Interview was conducted to TB
staff and Head of Medical Record at Gayamsari and
Karangdoro Public Health Center. The instrument of the
study was comprehensiveness checklist of medical record
and interview guidelines, the results are presented in
narratives and tabulations. Furthermore, the results will
be compared with the theory to be concluded and given the
solution for the medical record comprehensiveness. Based
upon the analysis result of TB 01 patient at Karangdoro
Public Health Center, 46% insufficient medical record
number data, 4% TB 05 address incomplete, found 11%
scribble on TB 01, 5% illegible writing on Document 05.
11% physical examination results, complete name and
signature of the TB 01 staff incomplete 4%. Quantitative
analysis result on Document 01 at Karangdoro Public
Health Center is patient identity data and medical record
number only noted on 29 documents (74,36%). Patient
data such as complete name, address, birth date and
gender recorded on all documents. Patient’s treatment
date also recorded. Found no scribble/undeleted data
on 33 documents (84,61%) and no writing mistake on 28
documents (71,80%). 32 complete diagnosis documents
(82,01%), 34 complete final treatment results documents
(87,18%), also 100% sort of therapy and contact
examination complete. 100% data of full name and
signature of the medical record staff unrecorded. Patient’s
diagnosis analysis results of 32 documents (82,01%)
are also consistent. So, analysis results of 29 documents
(74,36%) are valid and consistent. Medical record
document which quantitatively complete are accurate
reference for patient treatment. Insufficient data on
medical record documents become obstacles in compiling
Tuberculosis Integrated Information System (SITT), the
reports will be inaccurate. The accurate information has
impact on arranging suitable Tuberculosis prevention
government policy in each region. Making comprehensive
record data on TB 01 form with standar operating
procedures socializing to every Public Health Center Staff
will be the solutions. Also, as the part of medical record
document, TB 01 document should be stored combined
with the family folder, it should not be stored separately,
as found on Gayamsari and Karangdoro Public Health
Center at Semarang.