Review of The Completeness of Filling out the Medical Resume in the Child's Inpatient Room at Bhayangkara Hospital Tk.Ii Sartika Asih Bandung

Abstract

Medical resume is a summary of medical service activities provided by health workers, especially doctors during the treatment period, and patients come out both alive and dead. The medical resume should be fully and concise, with the name and signature of the doctor treating the patient and should be able to describe important information about the disease, the examination provided during treatment, and the care the patient received. This research method uses a type of quantitative research with a descriptive approach, data collection using interviews and observations. The results of this study found that incomplete fillings, including in actions that reached incompleteness reached 5 forms with a percentage of 6%, the name of the doctor 4 forms with a percentage of 5% and the most incomplete data was the condition when the patient went home as many as 14 forms from 80 samples taken reached a percentage of 15% incomplete data. And it is recommended that doctors and nurses work together to immediately fill out a medical resume sheet after the patient returns home from the treatment room or hospital. The medical records officer submits an incomplete report to the medical committee, the hospital leadership makes policies or procedures related to filling out the medical resume.