Completeness of Writing Patient Names in Hospitals

Fatika Puteri Rosyi Prabowo; Puput Mulyono

doi:10.59581/diagnosa-widyakarya.v2i4.4307

Authors

Fatika Puteri Rosyi Prabowo Universitas Duta Bangsa Surakarta
Puput Mulyono Universitas Duta Bangsa Surakarta

DOI:

https://doi.org/10.59581/diagnosa-widyakarya.v2i4.4307

Keywords:

Patient, Hospitals, Procedures

Abstract

Background: According to the Regulation of the Minister of Health of the Republic of Indonesia Number 24 of 2022 concerning Medical Records, they are documents that contain patient identity data, examinations, treatment, procedures and other services that have been provided to patients. Minimum Hospital Service Standards Completeness of filling in medical records 24 hours after completion must reach 100%. Objective: To determine the completeness factor in writing the patient's name in the patient's medical record at the hospital. Method: This research uses a literature review method. Results: The highest percentage of completeness in writing patient names was in research journals with a percentage of 98%, while the lowest percentage was 56%. Conclusion: From the results of a review of the completeness of writing patient names in hospital medical records, it was found that the completeness results were not 100% and not all hospitals had SOPs regarding procedures for writing patient names. Suggestion: Create an SPO for procedures for writing patient names that comply with standards so that officers can carry out these activities with guidelines. Background: In accordance with Republic of Indonesia Health Minister Regulation Number 24 of 2022, medical records are records that include information about a patient's identity, medical examinations, treatments, procedures, and other services rendered to them. Minimum Requirements for Hospital Services Within 24 hours of finishing, all medical records must be 100% complete. Goal: To ascertain the degree of completeness in entering the patient's name in the hospital's medical file. Method: A literature review approach is used in this study. Findings: Research journals had the highest percentage of complete patient names (98%) and the lowest percentage (56%) of complete patient names. Conclusion: A review of the completeness of writing patient names in hospital medical records revealed that not all hospitals have standard operating procedures (SOPs) pertaining to patient name writing, and the findings were not 100% complete. Recommendation: Establish a standard operating procedure (SPO) for writing patient names that adhere to standards so that officers can perform these tasks in accordance with protocols.

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