Analysis of Outpatient Medical Record Files Based on Accreditation Standards at The Karobengke Community Health Center

Abstract

File Analysis is a review of specific areas of the medical record to identify specific deficiencies. The designated areas are usually written in a procedure developed jointly by the health information manager and the health care provider in accordance with the medical staff rules and policies of the administration and the facility in question and the standards of licensing, accreditation and certification materials. This study aims to determine the analysis of medical record files for outpatients at the Katobengke Health Center in 2024. The method used is using a descriptive type of approach with a quantitative approach and the method of data collection techniques using interview methods, and observation. The population in this study amounted to 2,752 BRM. Sampling using random sampling technique and compressed using a formula which amounted to 96 BRM. The highest level of completeness in the identification component is the name subcomponent with a total of 95 with a percentage value of 99%. The highest level of completeness in the important report component is in the Complaints, Diagnosis, and Visit Date subcomponents with a total of 96 medical record files with a completeness percentage value of 100% The highest level of completeness in the authentication component is in the doctor's name subcomponent with a total of 86 medical record files with a completeness percentage value of 89%. The highest level of completeness in the correct documentation component is in the Legible Writing subcomponent with a total of 36 medical record files with a completeness percentage value of 37%. The suggestion for this study is that the hospital should conduct socialization or counseling to doctors, nurses and / or midwives to complete each available sheet to be completed.