Inpatients Medical Record Delay: A Problem Analysis in Medical Record Department

Abstract

Medical records are written as evidence of service processes performed on behalf of patients by doctors and other medical professionals. The deadline for returning medical records to the medical record facility is 2x24 hours from the patient's declaration of discharge by the patient's management. Based on the results of an initial survey in a form of a brief interview with the Head of the Medical Record Department at Al-Ihsan Hospital, the percentage of medical record returns from inpatients is still very low, less than 60%. This work highlights the analysis of the delayed return of medical records from the inpatient facility to the medical record storage room based on the completion of medical records, completeness of monitoring and evaluation, and compliance with the physician's obligations in completing the patient's medical records. This type of study is descriptive qualitative in the medical record-setting room at Al Ihsan Hospital. The results showed that, in terms of medical record completion, most physicians did not complete the patient's medical record. To include the primary diagnosis, physician's name, and signature. From the point of view of monitoring and evaluating medical records, medical records of inpatients are not monitored and evaluated by medical records due to the lack of staff at the medical record facility. On the other hand, from the perspective of physician compliance, more physicians are not compliant with filling out and filling out outpatient medical records.