ANALISIS KELENGKAPAN FORMULIR DISCHARGE SUMMARY PADA PASIEN RAWAT INAP GUNA MENUNJANG EFEKTIVITAS PELEPASAN INFORMASI

Abstract

This study aims to determine the completeness of filling out the discharge summary form in inpatients to support the effectiveness of the implementation of the release of medical information at RSIA Limijati Bandung.
The research method used is a qualitative research method with a descriptive approch. The sample collection technique used simple random sampling with the object of the study being 100 discharge summary forms from a total of 500 inpatient visits in April 2022 and 3 medical record officers. Based on the results of the study, there are 97% of the discharge summary forms are filled in completely and 3% are not filled out completely. The timeliness of releasing medical information has not been effective according to the Standard Operating Procedures (SOP), causing delays in the implementation of the release of medical information due to incomplete completion of the discharge summary form. The problem found was the lack of thoroughness of doctors in filling out the discharge summary form. So the author conveys his suggestions, namely evaluating the doctor who is responsible for filling out the discharge summary form and conducting field
Jurnal JMeRS Volume 1 Nomor 1 Tahun 2022 | 21
searches directly to the inpatient room while the patient is still being treated in order to avoid incomplete filling in the inpatient discharge summary form.
Keywords : Completeness, Discharge Summary, Release of Medical Information