EVALUASI MUTU REKAM MEDIS DI RS PKU 1 MUHAMMADIYAH YOGYAKARTA: STUDI KASUS PADA PASIEN SECTIO CAESARIA
Background :Healthcarein patients whocome for treatmentcan not be handledby one personalone. Because it isa means of communicationas a source ofpatient informationstoredsystematically. Medical recordsis one sourceinforrmasiwell as a meansof communicationneeded formedical servicesandadministrativeactivitiesatthe hospital. However, the management ofmedical recordshave so farhamperedthe low quality ofmedical records. Some studiesrevealincompletenessdocumentmedical records, doctorswritingdifficult to readandmanagementthat seemedsober. LikewiseinPKU Muhammadiyah Hospital inYogyakartawheremanagement ofmedical recordsthere areconstraints such asincompletefillingof doctors inthe medical records. Research Methods :This research is a qualitative descriptive research with case study design. Subjects were doctors, medical record quality control manager, and supervisor of data processing in medical records. Data collected by observation, document check medical records, interview the research subjects. Research Results :Completeness of medical records at PKU Muhammadiyah Hospital in Yogyakarta It is> 75% of the completeness of the medical record documents. Data were recorded accurately, Returns medical record file on time, already the SOP charging medical records, medical records format complexity, less a maximum of organizing medical records, existing storage procedures, extermination and confidentiality in medical records, and the less the maximum guidance and supervision of the management of PKU Muhammadiyah Hospital in Yogyakarta. Conclusion :Quality of Medical Records at PKU Muhammadiyah Hospital in Yogyakarta has been good only there are some advantages that already SOP is used as a standard in filling out medical records, has maximum storage efforts, extermination and confidentiality of medical records, but there are some obstacles include limitations charging time medical record, less maximum effort organizing, and less the maximum guidance and supervision of the management. Keywords :Quality of medical records, management of medical records, completness of medical records.