The Importance of Nurse Knowledge about Physical Examination and Inform on Medical Record Facility Inpatient Patient: Case Study in Sari Asih Hospital Karawaci Tangerang

Astri Annatasia, M. Reza Hilmy, Rokiah Kusumapradja, Erlina Puspitaloka Mahadewi

2018

Abstract

Based on the results of the observation in Sari Asih Hospital Karawaci Tangerang obtained medical record of hospitalized records are still many empty is that in 2016 there are 296 (3.4%) patients and in 2017 there are 405 (3.9%) patients. The incompleteness of medical record data mostly occurred on the accuracy of patient identity (name, a medical record number, place of birth date, sex) that is 37 patients (9%); and physical examination of 44 patients (11%), informed consent 47 (12%). The nurse's function as one of the data inputs that make the documentation of nursing care actions will affect the quality of the patient's medical records. The incompleteness of DRM is because there are still many nurses who have poor knowledge (60%) about medical records.The purpose of this research is to determine the effect of knowledge of nurses in filling out medical records on the completeness of medical records file of inpatients (case study in Rs. Sari Asih Karawaci Tangerang). The design of this study is associative causal (causal) with a quantitative approach. The object of this research is nurses in hospital wards as much,and samples counted 25 people with purposive sampling technique. Data collection by using primary data in the form of questionnaire/questionnaire and secondary data based on RM 2017 data which then analyzed by binary logistic regression analysis.Based on the result of regression logistic binary statistical analysis, it is found that the nurses' knowledge variable in the filling of the medical record has a significant effect on the accuracy of the medical records file of the inpatients The better the nurse's knowledge,the more complete the patient's medical record. Advice for hospitals to socialize, regularly monitor and evaluatenurses, about the importance of completeness in filling the medical record.

Paper Citation

in Harvard Style

Annatasia A., Hilmy M., Kusumapradja R. and Puspitaloka Mahadewi E. (2018). The Importance of Nurse Knowledge about Physical Examination and Inform on Medical Record Facility Inpatient Patient: Case Study in Sari Asih Hospital Karawaci Tangerang.In Proceedings of the 1st International Conference on Recent Innovations - Volume 1: ICRI, ISBN 978-989-758-458-9, pages 491-498. DOI: 10.5220/0009950704910498

in Bibtex Style

@conference{icri18,
author={Astri Annatasia and M. Reza Hilmy and Rokiah Kusumapradja and Erlina Puspitaloka Mahadewi},
title={The Importance of Nurse Knowledge about Physical Examination and Inform on Medical Record Facility Inpatient Patient: Case Study in Sari Asih Hospital Karawaci Tangerang},
booktitle={Proceedings of the 1st International Conference on Recent Innovations - Volume 1: ICRI,},
year={2018},
pages={491-498},
publisher={SciTePress},
organization={INSTICC},
doi={10.5220/0009950704910498},
isbn={978-989-758-458-9},
}

in EndNote Style

TY - CONF

JO - Proceedings of the 1st International Conference on Recent Innovations - Volume 1: ICRI,
TI - The Importance of Nurse Knowledge about Physical Examination and Inform on Medical Record Facility Inpatient Patient: Case Study in Sari Asih Hospital Karawaci Tangerang
SN - 978-989-758-458-9
AU - Annatasia A.
AU - Hilmy M.
AU - Kusumapradja R.
AU - Puspitaloka Mahadewi E.
PY - 2018
SP - 491
EP - 498
DO - 10.5220/0009950704910498