INFORMATION SYSTEM DESIGN ANALYSIS OF INPATIENT MEDICAL RECORD FORM COMPLETENESS IN XYZ HOSPITAL

Abstract

This study aims to evaluate and improve the information system for ensuring the completeness of medical record forms. A qualitative research method is used, with data collection through observation, interviews, and literature review. The research identifies several issues in the current system for managing outpatient medical record forms: reports on the completeness of these forms are still created manually and are not yet computerized, resulting in frequent delays. Additionally, diagnoses written by nurses or doctors are sometimes difficult to read, which leads staff to make assumptions about the intended diagnosis. Furthermore, diagnoses are not codified using ICD-10 standards.

To address these issues, the following recommendations are proposed: the hospital should implement an information system for tracking the completeness of medical record forms to improve hospital operations, particularly the reporting process. Diagnoses should be coded according to ICD-10 standards, and reporting staff should be able to complete reports on the completeness of medical record forms promptly to avoid delays. Training programs should also be conducted to enhance the quality of human resources.