A short review on quality assurance in patient’s medical record and medical ethics
List of Authors
  • Rina Ayuningsih , Siti Amira Othman

Keyword
  • quality assurance, patient, medical records, medical ethics

Abstract
  • The quality of quality assurance of patients' medical records in hospitals needs to be considered and continues to be improved. To measure good service quality indicators, medical records must always improve the completeness of patient documents. Quality Assurance, Quality Medical records officers, among others, are obliged to perform: quantitative analysis and qualitative analysis. Based on several studies in various hospitals, the completeness of inpatient medical records files ranges from 70% - 80% of 100%. Many things happen, one of which is about human resources that are influenced by behavior, the implementation of operational standards in filling medical records, file punishment and rewards. Completeness of medical resume is a reflection of the quality of medical records and services provided by the hospital. The writing of the diagnosis is filled out completely and as directed on ICD-10. This review paper was made to find out how the quality assurance quality of patients' medical records is accompanied by factors that affect the quality assurance of medical records, as well as to dig up information on the completeness of medical resumes and the suitability of diagnosis writing based on ICD-10. The results showed that the quality assurance of patients' medical records was influenced by several factors, including human resources, facilities and infrastructure and monitoring and policy assessment related to quality assurance of medical records. Hospitals must implement SIMRS to improve the speed and accuracy of filling medical records including medical resumes. Besides that, ethics guidelines was implemented to all hospital around the world. By implemented this ethics during examining can build trust and understanding about issues of their patient.

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