Evaluation of minimum service standards hospital of medical records service type in dr. Soekardjo General Hospital Tasikmalaya

Abstract

The type of medical record service based on a minimum service standard hospital has four indicators such as
completeness of medical records 24 hours after finishing of service is 100%, completeness of informed consent form after
receiving clear information is 100%, time provision of medical records outpatient services with standard time ≤ 10 minutes
and the provision of inpatient medical records to standard time ≤ 15 minutes. Results of a preliminary study on January 29
2016, the most cases surgery is biopsy/extirpation. The highest incompleteness is in the recording, 100% incomplete. The
purpose of this study is to evaluate the implementation of the Minimum Service Standards Hospital medical record service
types. This study uses a sequential mixed method. Samples were taken using total sampling technique number of 59
documents. Subjects selected by purposive sampling. The instruments used are as interview guides and observation sheet.
The data collection is done by observation, in-depth interviews and Focus Group Discussion. The results showed a provision
of time is ± 4 minutes, completeness of medical record documents 24 hours after the servicing consist of the completeness of
patient identity (highest item name are57.63%), Review of the Important Report (the highest of action items are76.27%),
Filling authentication (highest item signature of doctor/nurse are 62.71%) and a good documentation (highest item clearly
readable recording are 30.51%). Filling informed consent form is not yet complete. The hospital already implementing
evaluation of the minimum service standards but for completeness of medical record document has not been a priority.