量化分析:2021年,母亲、母亲、儿童、小儿麻痹症普立瓦普拉瓦德(PUSKESMAS PLAWAD)医疗policlinic and child poskesmas PLAWAD处的住院医生表格完整

None Anas Fajry Rhomadon, None Daniel Happy Putra, None Lily Widjaja, None Puteri Fannya
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引用次数: 0

摘要

医疗记录是向患者提供的身份、检查、治疗、行动和服务的文件。怀孕期间的保健服务必须记录在母亲卡、医疗记录、母亲队列和母婴保健书中。产妇队列是从母亲卡中收集的数据集合。该文件必须填写完整,因为它影响到必要时的进一步联系,在某些情况下,需要进行医疗审计。本研究旨在确定2021年在Poris Plawad卫生中心妇幼综合诊所填写母亲队列表的完整性。本研究采用定量描述方法。使用slovin公式确定样本数量,从而获得68个产妇队列的样本数据。从68个产妇队列数据中获得的研究结果显示,鉴定的平均完整性(77%)、重要报告(62%)和记录程序(49%)的平均完整性。影响不完整性的因素有:缺少产妇队列填写SOP,没有更新指南,没有记录病案编号,工作人员沟通少,没有填写认证栏,双重工作表格。研究人员的建议是更新指南,在母亲队列中创建SOP填写并开展外展,更新表格以添加认证记录,开展培训/研讨会以增加助产士的见解,并设计一个可操作的系统,由1人以上的人在系统中记录健康数据。
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ANALISIS KUANTITATIF KELENGKAPAN FORMULIR KOHORT IBU DI BAGIAN POLIKLINIK KESEHATAN IBU DAN ANAK PUSKESMAS PORIS PLAWAD TAHUN 2021
Medical records are documentation of identity, examination, treatment, actions, and services that have been provided to patients. Health services during pregnancy must be documented in the mother's card, medical record, mother's cohort, and mother and child health book. The maternal cohort is a collection of data collected from the mother's card. The documentation must be filled in completely because it affects further contact if needed and in certain circumstances, it is required for a medical audit. This study aims to determine the completeness of filling out the mother's cohort form at the MCH polyclinic at the Poris Plawad Health Center in 2021. This study used a quantitative descriptive method. Determining the number of samples using the slovin formula, so that a sample of 68 maternal cohort data was obtained. The results of the research from 68 maternal cohort data obtained an average of completeness of identification (77%), important reports (62%), and procedures for documentation (49%). Factors that influence incompleteness are the absence of an SOP for Filling in the Maternal Cohort, no updating of guidelines, no recording of medical record numbers, less communicative staff, no column for filling in authentication, and double working forms. Suggestions from researchers are to update the guidelines, create SOP Filling in the Cohort of Mothers and carry out outreach, update forms to add authentication records, conduct training/seminars to increase midwifery insights, and devise a workable system of more than 1 person for recording health data in the system.
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