UGC Approved Journal no 63975(19)

ISSN: 2349-5162 | ESTD Year : 2014
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Published in:

Volume 7 Issue 11
November-2020
eISSN: 2349-5162

UGC and ISSN approved 7.95 impact factor UGC Approved Journal no 63975

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Published Paper ID:
JETIR2011330


Registration ID:
303771

Page Number

258-261

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Title

Incompleteness Analysis of Medical Record Data on Inpatient Discharge Summary

Authors

Abstract

Hepatoma or hepatocellular carcinoma (KHS) is a primary malignant tumor of the liver originating from hepatocytes and the 3rd cause of death from cancer in the world. The history of a hepatoma patient can be seen based on the patient's medical record. The filling of medical record is done by doctors, nurses / midwives and medical record personel. However, in medical record filling, incompleteness is often found and cause inaccurate information. The study design used a retrospective analysis approach. Variable in the study were incompleteness; authentication and documentation on patient discharge summary form. Population in this study is inpatient medical records for Hepatoma cases in a Padang City Hospital from January to March 2019 were 75 medical record documents (discharge summary form) inpatients with hepatoma cases. The results indicated that there were incompletenesses on discharge data, date of birth, gender, name of the consular doctor, name of the doctor who sent, address, diagnosis, ICD code, procedure code, discharge status, follow-up, patient or family signature. The largest incompleteness filling out the discharge summary form is found in address data items as many as 46 medical records (61%).

Key Words

Medical record, incompleteness, inpatient summary discharge

Cite This Article

"Incompleteness Analysis of Medical Record Data on Inpatient Discharge Summary", International Journal of Emerging Technologies and Innovative Research (www.jetir.org), ISSN:2349-5162, Vol.7, Issue 11, page no.258-261, November-2020, Available :http://www.jetir.org/papers/JETIR2011330.pdf

ISSN


2349-5162 | Impact Factor 7.95 Calculate by Google Scholar

An International Scholarly Open Access Journal, Peer-Reviewed, Refereed Journal Impact Factor 7.95 Calculate by Google Scholar and Semantic Scholar | AI-Powered Research Tool, Multidisciplinary, Monthly, Multilanguage Journal Indexing in All Major Database & Metadata, Citation Generator

Cite This Article

"Incompleteness Analysis of Medical Record Data on Inpatient Discharge Summary", International Journal of Emerging Technologies and Innovative Research (www.jetir.org | UGC and issn Approved), ISSN:2349-5162, Vol.7, Issue 11, page no. pp258-261, November-2020, Available at : http://www.jetir.org/papers/JETIR2011330.pdf

Publication Details

Published Paper ID: JETIR2011330
Registration ID: 303771
Published In: Volume 7 | Issue 11 | Year November-2020
DOI (Digital Object Identifier):
Page No: 258-261
Country: Padang, West Sumatera, Indonesia .
Area: Management
ISSN Number: 2349-5162
Publisher: IJ Publication


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