ASSISTANCE IN UNDERSTANDING THE BENEFITS OF MEDICAL RECORDS FOR PATIENT AND HEALTHCARE WORKER SAFETY AT MADANI GENERAL HOSPITAL

Abstract

Patient safety is a system that makes patient care safer, including risk assessment, patient risk identification and management, incident reporting and analysis, the ability to learn from incidents and follow-up actions, as well as the implementation of solutions to minimize the emergence of risks and prevent injuries caused by errors resulting from performing an action or failing to take an action that should have been taken. Patient safety is a particular challenge for healthcare facilities because it requires awareness and knowledge from all involved parties, starting from medical personnel and continuing to other healthcare workers, as well as from patients and their families. Knowledge regarding the benefits of medical records for patient safety and healthcare workers is very important for patients, their families, and healthcare workers to understand. This aims to prevent potential risks and maintain the safety of both patients and healthcare workers. These educational efforts represent one of the risk or accident control strategies for patients and healthcare workers. The completeness of medical records at Madani Regional Hospital is considered quite good, although some incompleteness is still found, especially regarding the doctor's signature. The documentation of medical records must be completed no later than 1x24 hours after the patient receives healthcare services, under various provisions. In practice, doctors and other healthcare workers providing medical services are obliged to document medical records and complete them by writing their full name and the date.The community service method is descriptive. There were three informants: the Person in Charge of Medical Records and two officers responsible for analyzing the completeness of medical records. Data collection techniques included observation and interviews. Data sources consisted of primary and secondary data. Data processing used triangulation techniques, and descriptive data analysis employed qualitative methods.Results of the service: There are 12 human resources in medical records working in three different shifts with backgrounds in medical records. The completeness of medical records is fairly good, although this is hindered by the absence of doctor's signatures, clear names, and final diagnoses. Regarding training, not all staff have participated.Conclusion: The number of medical records human resources who have received training is not evenly distributed, especially among healthcare workers involved in filling out medical records. Furthermore, the implementation of medical record completeness has not been carried out optimally.