Qualitative Analysis Factors That Influence The Performance Of Doctors In The Complete Recording Of Inpatient Medical Records At H Sahudin Kutacane Hospital In Southeast Aceh
Qualitative Analysis Factors that Influence the Performance of Doctors in the Complete Recording of Inpatient Medical Records at H Sahudin Kutacane Hospital, Southeast Aceh
Introduction
Medical records are a crucial component of the healthcare process, containing vital information about patients, diagnosis, treatment, and medical actions taken. These records must be complete, accurate, and easily accessible to support treatment, research, and education. However, the completeness of medical records is often a concern in many healthcare institutions, including H Sahudin Kutacane Hospital in Southeast Aceh. This study aims to investigate the factors that influence the performance of doctors in the completeness of recording inpatient medical records at this hospital.
Background
Medical records are a vital tool in the healthcare process, providing a comprehensive record of a patient's medical history, diagnosis, treatment, and outcomes. These records are essential for ensuring the continuity of care, facilitating communication among healthcare providers, and supporting research and education. However, the completeness of medical records is often a concern, with many healthcare institutions struggling to maintain accurate and up-to-date records.
Methodology
This qualitative study involved all general practitioners and specialists at H Sahudin Kutacane Hospital as informants. Data was collected through narratives about the factors that influenced the performance of doctors in the completeness of medical record recording. The data was analyzed to identify the main factors that affected the doctor's performance in the completeness of medical record recording.
Results
The results of this study showed that several main factors affected the doctor's performance in the completeness of medical record recording. These factors include:
Motivation
Doctor's motivation to complete the medical record is very important. Some doctors may be less motivated because they feel the medical record recording process takes time and is not too important. A lack of motivation can lead to incomplete or inaccurate medical records, which can have serious consequences for patient care.
Knowledge
Knowledge of the importance of complete medical records and correct filling procedures is very necessary. Doctors who do not understand about this may tend to reduce the completeness of medical record recording. This highlights the need for ongoing education and training for healthcare providers to ensure they have the necessary knowledge and skills to complete medical records accurately.
Attitude
The doctor's attitude towards the record of medical records is also influential. Doctors who have a positive attitude and consider recording medical records as important things will be more likely to complete the medical record well. A positive attitude can help to motivate doctors to complete medical records accurately and efficiently.
Leadership
Leadership and supervision from hospital management also have an important role. Clarity of Standard Operating Procedures (SOP) and strict supervision will encourage doctors to be more disciplined in completing medical records. Effective leadership and supervision can help to ensure that medical records are completed accurately and efficiently.
Discussion
The results of this study highlight the importance of motivation, knowledge, attitude, and leadership in ensuring the completeness of medical record recording. These factors are interconnected and can have a significant impact on the quality of medical records. A lack of motivation, knowledge, or positive attitude can lead to incomplete or inaccurate medical records, while effective leadership and supervision can help to ensure that medical records are completed accurately and efficiently.
Conclusion
This study has shown that several main factors affect the doctor's performance in the completeness of medical record recording at H Sahudin Kutacane Hospital. These factors include motivation, knowledge, attitude, and leadership. To increase the completeness of medical record recording, hospital management needs to clarify SOPs, conduct sustainable socialization, increase doctor's motivation, and conduct effective supervision. By applying these recommendations, it is hoped that there will be an increase in doctor's performance in the completeness of medical record recording, ensuring the quality of health services at H Sahudin Kutacane Hospital.
Recommendations
Based on the results of this study, several recommendations can be made to increase the completeness of medical record recording at H Sahudin Kutacane Hospital:
Clarify SOPs
Hospital management needs to make a clear SOP and is easily understood by all health workers, especially doctors, regarding the process of recording medical records.
Sustainable Socialization
Socialization of the importance of recording medical records needs to be done routinely and continuously to all hospital components, especially doctors. This socialization can be done through seminars, training, or routine meetings.
Increasing Doctor's Motivation
Hospital management needs to create programs and strategies to increase doctor's motivation in completing medical records. This can be done by giving awards to doctors who have complete and accurate medical records.
Effective Supervision
Hospital management needs to conduct more effective supervision of the medical record recording process. This can be done by forming a special team whose job is to check the completeness and accuracy of the medical record.
Coordination between Units
Hospital management needs to coordinate between units to discuss problems related to the record of medical records. Routine meetings can be done to evaluate findings and find joint solutions to overcome the problem of incomplete medical records.
By applying these recommendations, it is hoped that there will be an increase in doctor's performance in the completeness of medical record recording, ensuring the quality of health services at H Sahudin Kutacane Hospital.
Frequently Asked Questions (FAQs) about Qualitative Analysis Factors that Influence the Performance of Doctors in the Complete Recording of Inpatient Medical Records at H Sahudin Kutacane Hospital
Q: What is the importance of medical records in healthcare?
A: Medical records are a crucial component of the healthcare process, containing vital information about patients, diagnosis, treatment, and medical actions taken. These records must be complete, accurate, and easily accessible to support treatment, research, and education.
Q: What are the main factors that affect the doctor's performance in the completeness of medical record recording?
A: The main factors that affect the doctor's performance in the completeness of medical record recording include motivation, knowledge, attitude, and leadership.
Q: What is the role of motivation in medical record recording?
A: Motivation is a crucial factor in medical record recording. Doctors who are motivated to complete medical records accurately and efficiently are more likely to do so. A lack of motivation can lead to incomplete or inaccurate medical records.
Q: What is the importance of knowledge in medical record recording?
A: Knowledge of the importance of complete medical records and correct filling procedures is very necessary. Doctors who do not understand about this may tend to reduce the completeness of medical record recording.
Q: How can hospital management increase doctor's motivation in completing medical records?
A: Hospital management can increase doctor's motivation in completing medical records by creating programs and strategies to motivate doctors, such as giving awards to doctors who have complete and accurate medical records.
Q: What is the role of leadership in medical record recording?
A: Leadership and supervision from hospital management also have an important role in medical record recording. Clarity of Standard Operating Procedures (SOP) and strict supervision will encourage doctors to be more disciplined in completing medical records.
Q: How can hospital management conduct effective supervision of the medical record recording process?
A: Hospital management can conduct effective supervision of the medical record recording process by forming a special team whose job is to check the completeness and accuracy of the medical record.
Q: What is the importance of coordination between units in medical record recording?
A: Hospital management needs to coordinate between units to discuss problems related to the record of medical records. Routine meetings can be done to evaluate findings and find joint solutions to overcome the problem of incomplete medical records.
Q: What are the benefits of increasing the completeness of medical record recording?
A: Increasing the completeness of medical record recording can have several benefits, including improved patient care, better communication among healthcare providers, and enhanced research and education.
Q: How can hospital management implement the recommendations from this study?
A: Hospital management can implement the recommendations from this study by clarifying SOPs, conducting sustainable socialization, increasing doctor's motivation, and conducting effective supervision.
Q: What are the next steps for hospital management to improve medical record recording?
A: The next steps for hospital management to improve medical record recording include implementing the recommendations from this study, monitoring progress, and making adjustments as needed.
By answering these frequently asked questions, we hope to provide a better understanding of the factors that influence the performance of doctors in the complete recording of inpatient medical records at H Sahudin Kutacane Hospital and the importance of improving medical record recording.