Relationship Of Interna Medicine Specialist Doctor Knowledge With Completeness Of Integrated Outstanding Patient's Development Notes At Udayana University Hospital

I Dewa Ayu Eka Budiani; Ika Setya Purwanti; Putu Ayu Sri Murcittowati

Authors

I Dewa Ayu Eka Budiani STIKES Wira Medika Bali
Ika Setya Purwanti STIKES Wira Medika Bali
Putu Ayu Sri Murcittowati RSUD Wangaya Kota Denpasar

Keywords:

CPPT, Physician Knowledge and Discipline, Interna Specialist

Abstract

Integrated Patient Development Records (CPPT) is the documentation for health workers in reassessing patient's inpatients according to Hospital Accreditation standards. The CPPT is an integrated patient care communication media for health workers to write patient data and treatment plans. The CPPT sheet contains three main components: patient identification, essential records, and patient authentication. The function of collaboration and communication between health professionals will appear in the CPPT form at the hospital. The characteristics of doctors in supporting the completeness of filling out medical records can be seen from specialist doctors' knowledge level. This study aimed to determine the relationship between the knowledge and completeness level of filling out CPPT inpatients by interna specialists at Udayana University Hospital. The research method used in this study is quantitative analysis with a total sample of 85 medical records of interna inpatients and five respondents of interna specialists by using the Probability sampling method, namely random sampling. The results showed that from 5 interna specialist doctors at Udayana University Hospital, it was found that three doctors understood and two doctors did not understand. Of the 85 medical record files studied, the incompleteness of the CPPT form reached 12.96%, while the completeness of the CPPT form reached 87.06%. The results of the Chi-Square test resulted in a p-value of 0.016. This proves that there is a relationship between the level of knowledge and the completeness of the inpatient integrated patient development record form at Udayana University Hospital.

References

D. Riyantika, “Analisis Faktor-Faktor Penyebab Ketidaklengkapan Pengisian Lembar Resume Medis Pasien Rawat Inap,” Str. J. Ilm. Kesehat., vol. 7, no. 1, pp. 69–73, 2018.

S. E. Rikomah, Farmasi Rumah Sakit. Deepublish, 2017.

S. J. Swari, G. Alfiansyah, R. A. Wijayanti, and R. D. Kurniawati, “Analisis Kelengkapan Pengisian Berkas Rekam Medis Pasien Rawat Inap RSUP Dr. Kariadi Semarang,” Arter. J. Ilmu Kesehat., vol. 1, no. 1, pp. 50–56, 2019.

N. Nurhaidah, T. Harijanto, and T. Djauhari, “Faktor-Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Rawat Inap di Rumah Sakit Universitas Muhammadiyah Malang,” J. Kedokt. Brawijaya, vol. 29, no. 3, pp. 258–264, 2016.

N. Nuryani and D. D. Susanti, “Hubungan pengetahuan perawat dengan kelengkapan dokumentasi asuhan keperawatan di RSUD dr. Soekardjo Kota Tasikmalaya,” J. Manaj. Inf. Kesehat. Indones., vol. 2, no. 2, 2014.

A. Ayuningtyas, A. T. Susilani, and F. Hakam, “Hubungan Tingkat Pengetahuan Tentang Rekam Medis Dengan Kelengkapan Lembar Anamnesa Oleh Bidan Di Bangsal Kebidanan Rumah Sakit Nur Hidayah Bantul,” JPermata Indones. Nov, vol. 6, no. 2, pp. 1–9, 2015.

S. Setiatin and S. Laksamana, “Pengaruh Kelengkapan Pengisian Catatan Perkembangan Pasien Terintegrasi (CPPT) Rawat Inap Terhadap Penilaian Standar 13.3 Manajemen Informasi Rekam Medis Versi Snars Di Santosa Hospital Bandung Kopo,” INFOKES (Informasi Kesehatan), vol. 2, no. 2, pp. 94–107, 2018.

S. Sarosa, Analisis Data Penelitian Kualitatif. PT Kanisius, 2021.

Y. Lestari, A. Saleh, and S. Pasinringi, “Hubungan Interprofessional Kolaborasi dengan Pelaksanaan Catatan Perkembangan Pasien Terintegrasi di RSUD Prof Dr HM Anwar Makkatutu Kabupaten Bantaeng,” J. Kesehat., vol. 7, no. 1, pp. 85–90, 2017.

A. Anggito and J. Setiawan, Metodologi penelitian kualitatif. CV Jejak (Jejak Publisher), 2018.

Notoadmodjo, Promosi Kesehatan dan Perilaku Kesehatan. Jakarta: PT. Rineka Cipta, 2012.

G. R. Hatta, “Pedoman Manajemen Informasi Kesehatan di sarana pelayanan kesehatan,” Jakarta Univ. Indones., 2008.

R. R. Kumalasari, Y. Dharmawan, and S. Winarni, “Hubungan Pengetahuan, Sikap Dan Usia Dokter Terhadap Kelengkapan Pengisian Berkas Rekam Medis Pada Pasien BPJS Di Rumah Sakit Aisyiyah Bojonegoro,” J. Kesehat. Masy., vol. 6, no. 4, pp. 125–131, 2018.

Y. Eny and R. Enny, “Hubungan Pengetahuan Dokter Dengan Kelengkapan Dokumen Rekam Medis Rawat Jalan di Poliklinik Neurologi RSUP. Dr. Kariadi Semarang Oktober 2008,” J. Visikes, vol. 3, no. 2, pp. 17–28, 2008.

R. Herdiyanti, “Analisis Pelayanan Kesehatan Bagi Pasien Badan Penyelenggara Jaminan Sosial (BPJS) Di Puskesmas Ukui Kabupaten Pelalawan.” Universitas Islam Riau, 2021.