HUBUNGAN KELENGKAPAN RESUME MEDIS DENGAN KETEPATAN WAKTU PENGEMBALIAN REKAM MEDIS PASIEN RAWAT INAP DI UPTD KHUSUS RS JIWA PROF. DR. MUHAMMAD ILDREM TAHUN 2026

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Advisor(s) PUTRI, RIZQI NANDA
Author(s) KEMIT, ERVIANI
Issued Date 2026
Abstract Kemit, Erviani. The Relationship Between the Completeness of Medical Summaries and the Timeliness of Returning Inpatient Medical Records at the Prof. Dr. Muhammad Ildrem Mental Hospital (Special Regional Technical Implementation Unit), Medan, in 2026. Undergraduate Thesis, Department of Health Information Management, Faculty of Public Health, Deli Husada Deli Tua Health Institute. (Supervised by: Rizqi Nanda Putri, S.Kes., M.K.M.) Background: Medical records installations must maintain medical records correctly, completely and precisely, including completing medical resumes and returning medical records. According to the Indonesian Ministry of Health (2006), the standard for returning inpatient medical records is ≤ 2x24 hours after completion of treatment. Completeness of a medical resume includes components of the patient's identity, diagnosis, examination results and treatment, the name and signature of the treating doctor on the patient's medical resume. Bearing in mind the importance of a complete medical resume in providing complete and accurate information to ensure the continuity of medical services as well as the correct return of medical records for the smooth processing of medical data in hospitals. Objective: To determine the relationship between the completeness of a medical resume and the timeliness of returning inpatient medical records at the Prof. Dr. Muhammad Ildrem Mental Hospital (Special Regional Technical Implementation Unit), Medan, in 2026. Research Method: Quantitative method with Cross Sectional research design. The population in this study was inpatient medical record documents in January 2026 to March 2026. The total sample was 76 using the Random Sampling formula. Data collection using a check list sheet. Univariate analysis uses frequency distribution and bivariate analysis with Continuity Correctionb Using the Chi square test.Research Results: The percentage of complete completion of medical resumes was 71.1% and incomplete 28.9%, returning medical records on time was 84.2% and not on time 15.8%. The Continuity Correction value is 0.499, so the p-value is (0.499 > 0.05). Conclusion: There is no relationship between the completeness of a medical resume and the timeliness of returning inpatient medical records at the Prof. Dr. Muhammad Ildrem Mental Hospital (Special Regional Technical Implementation Unit), Medan, in 2026. Suggestion: Hospital leaders need to socialize standard operating procedures (SPO) regarding the completeness of filling out medical resumes and returning medical records correctly so that health workers carry out them in accordance with hospital procedures. 1
Item Type Skripsi
Keywords Kelengkapan(Completeness), ketepatan (accuracy), rekam medis (medical records). 1
Collection Fakultas Kesehatan Masyarakat, D4-Manajemen Informasi Kesehatan
Publisher INSTITUT KESEHATAN DELI HUSADA
Submitted Date 23-10-2026
Updated Date 23-10-2026
URI No URI
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