导致医院住院病人医疗简历填写不完整的因素:文献综述

H. Hendro, Ascobat Gani
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引用次数: 0

摘要

医疗简历或病史摘要必须填写完整,包含有关疾病、检查和治疗的重要信息,完整性标准为 100%。不完整的简历将破坏流程的连续性和患者的安全。本研究的目的是根据 5M 管理要素,即人(Man)、钱(Money)、方法(Method)、材料(Material)和机器(Machine),分析导致医院住院病人医疗简历填写不完整的因素。采用的研究方法是文献综述。使用谷歌学术数据库搜索文章,并根据纳入和排除标准进行筛选。找到的文献数量为 8 种期刊。本研究的结果来自于以下要素:人力资源数量有限、工作量大、时间限制、官员对填写简历的重要性缺乏了解以及没有对官员进行培训。资金要素,资金来源没有限制。要素法,即 SOP 缺乏社会化,SOP 尚不存在,没有制度奖惩,SOP 不够详细,没有对简历完整性的评估。素材,即简历填写项目较简单。要素机,即设施和基础设施不完善,档案分发慢。解决的办法是计算工作量、落实纪律态度、提供培训、编制专项预算、制定 SOP 并使之社会化、提供奖惩措施、重新设计简历表、完善病历科的设施和基础设施。
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Factors Causing Incomplete Filling of Medical Resumes of Inpatients in Hospitals: Literature Review
The medical resume or summary of the patient's history must be filled out completely, containing important information about the disease, examination and treatment provided with a standard of 100% completeness. Incomplete resumes will disrupt process continuity and patient safety. The aim of this research is to analyze the factors that cause incomplete filling out of medical resumes for inpatients in hospitals based on the management elements consisting of 5M, namely Man, Money, Method, Material, and Machine. The research method used is a literature review. Search articles using databases Google Scholar with selection according to inclusion and exclusion criteria. The number of literature found was 8 journals. The results obtained in this research are from the elements man limited number of human resources, high workload, time constraints, lack of understanding by officers regarding the importance of filling out resumes, and no training for officers. Element money, there are no constraints on funding sources. Element method namely lack of socialization of SOPs, SOPs do not yet exist, there is no system reward and punishment, SOP is not detailed enough, there is no evaluation of resume completeness. Element material, that is, the resume filling items are less simple. Element machine, namely inadequate facilities and infrastructure and slow distribution of files. The solutions taken to overcome this are calculating the amount of workload, implementing a disciplined attitude, providing training, preparing a special budget, creating and socializing SOPs, providing reward and punishment. redesigning resume forms, completing facilities and infrastructure in the medical records unit.
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