scholarly journals Study Literature Review On Returning Medical Record Documents Using HOT-FIT Method

2021 ◽  
Vol 1 (1) ◽  
pp. 61-65
Author(s):  
Deni Maisa Putra ◽  
Oktamianiza Oktamianiza ◽  
Mega Yuniar ◽  
Washi Fadhila
Keyword(s):  
Literature Review ◽  
Medical Record ◽  
Medical Records ◽  
Descriptive Analysis ◽  
Net Benefit ◽  
Literature Study ◽  
Return Policy ◽  
Record Section ◽  
Doctors And Nurses

The return of medical record files is a system that is quite important in medical records, because the return of medical records starts from the file in the inpatient room until it returns to the medical record section in accordance with the return policy, which is 2x24 hours. The method used is a literature study with descriptive analysis which is done by describing the facts that exist then being analyzed, described, looking for similarities, views, and summaries of several studies. The results of the literature study show that humans are not responsible for returning medical record files, the organization lacks supervision from the management of returning files, technology (technology) with technology can assist in returning medical record files. So it is necessary to pay attention to the 3 components, so that it can produce a benefit (Net Benefit) from returning the medical record document. Based on the results of the study, it can be concluded that the factors that influence the return of medical record documents are in terms of the HOT-FIT method, (human) where the officers lack a sense of responsibility for medical record documents, and doctors and nurses do not pay attention to the form of filling out record documents medical records, so that it becomes an obstacle in returning medical record documents. It's good to have good supervision from the management.

A Literature Review of Medical Record Keeping by Foreign Medical Teams in Sudden Onset Disasters

2015 ◽  
Vol 30 (2) ◽  
pp. 216-222 ◽  
Author(s):  
Anisa J. N. Jafar ◽  
Ian Norton ◽  
Fiona Lecky ◽  
Anthony D. Redmond
Keyword(s):  
Literature Review ◽  
Medical Record ◽  
Medical Records ◽  
Sudden Onset ◽  
World Health ◽  
Publication Type ◽  
Data Set ◽  
Record Keeping ◽  
Medical Teams

AbstractBackgroundMedical records are a tenet of good medical practice and provide one method of communicating individual follow-up arrangements, informing research data, and documenting medical intervention.MethodsThe objective of this review was to look at one source (the published literature) of medical records used by foreign medical teams (FMTs) in sudden onset disasters (SODs). The published literature was searched systematically for evidence of what medical records have been used by FMTs in SODs.FindingsThe style and content of medical records kept by FMTs in SODs varied widely according to the published literature. Similarly, there was great variability in practice as to what happens to the record and/or the data from the record following its use during a patient encounter. However, there was a paucity of published work comprehensively detailing the exact content of records used.InterpretationWithout standardization of the content of medical records kept by FMTs in SODs, it is difficult to ensure robust follow-up arrangements are documented. This may hinder communication between different FMTs and local medical teams (LMTs)/other FMTs who may then need to provide follow-up care for an individual. Furthermore, without a standard method of reporting data, there is an inaccurate picture of the work carried out. Therefore, there is not a solid evidence base for improving the quality of future response to SODs. Further research targeting FMTs and LMTs directly is essential to inform any development of an internationally agreed minimum data set (MDS), for both recording and reporting, in order that FMTs can reach the World Health Organization (WHO) standards for FMT practice.JafarAJN, NortonI, LeckyF, RedmondAD. A literature review of medical record keeping by foreign medical teams in sudden onset disasters. Prehosp Disaster Med. 2015;30(2):1-7.

scholarly journals Aspek Hukum Rekam Medis atau Rekam Medis Elektronik sebagai Alat Bukti Dalam Transaksi Teurapetik

2017 ◽  
Vol 3 (2) ◽  
pp. 359-383 ◽  
Author(s):  
Sudjana Sudjana
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Medical Records ◽  
Health Workers ◽  
Legal Aspects ◽  
Literature Study ◽  
Descriptive Research ◽  
Positive Law ◽  
Approach Method ◽  
Administrative Sanctions

This study aims to obtain information on: first, the obligation to create and conceal Electronic Medical Record and its juridical consequences; Secondly, due to the law of absence or error in the manufacture of Electronic Medical Records and the position of Electronic Medical Record as a tool in the theoretical transactions.The research method used is normative juridical approach method, analytical descriptive research specification, research phase is done through literature study to examine primary law material, secondary law material, and tertiary law material. Data collection techniques are conducted through document studies, conducted by reviewing documents on positive law. Furthermore, the method of data analysis is done through normative qualitative.The results of the study indicate: Legal aspects of Medical Record or Electronic Medical Record   in Teurapetik Transactions related to: first, the obligation of health workers in coaching and health services to make Medical Record or Electronic Medical Record correctly and responsible for secrecy because it is the opening of Medical Record or Electronic Medical Record without With the permission of the patient having the consequences of criminal law. The absence or misuse of the Medical Record or Electronic Medical Record means that health workers may be subject to criminal, civil and administrative sanctions. Second, the position of  Medical Record or Electronic Medical Record is evidence in the form of a letter (if given outside the court), and expert information (if delivered in court).

scholarly journals Análise do deep learning em cuidados de saúde

2019 ◽  
Vol 13 ◽  
Author(s):  
Flávio Vaz Machado ◽  
Liszety Guimarães Emmerick ◽  
Roberto Carlos Lyra da Silva ◽  
Luiza Cerqueira Reis da Costa ◽  
Fernanda Rodrigues da Silva ◽  
...  
Keyword(s):  
Health Care ◽  
Deep Learning ◽  
Literature Review ◽  
Descriptive Analysis ◽  
Descriptive Study ◽  
Daily Activities ◽  
Precise Identification ◽  
Disease Stages ◽  
Doctors And Nurses

Objetivo: analisar a aplicabilidade e os benefícios do Deep Learning na área de cuidados de saúde. Método: trata-se de um estudo descritivo, tipo análise reflexiva, com consulta a artigos entre os anos de 2014 a 2019, publicados em inglês e revisado por pares, no Portal de Periódicos da CAPES, com a equação de busca (“Deep Learning” AND (“Health Care” OR Health-care OR Healthcare)). Apresentaram-se os resultados em forma de figura seguida da análise descritiva. Resultados: revela-se que 15 artigos descrevem a aplicabilidade do Deep Learning na área de cuidados de saúde. Analisou-se, por este artigo, o emprego do Deep Learning em diferentes áreas referentes aos cuidados de saúde, destacando os benefícios encontrados pelos autores dos selecionados por meio da revisão de literatura. Conclusão: sugere-se o emprego do Deep Learning na área de cuidados de saúde diante dos benefícios identificados nos artigos selecionados como: a previsão dos estágios das doenças; a identificação precisa de mutações patológicas e o suporte aos médicos e aos enfermeiros em suas atividades diárias. Descritores: Benefícios; Deep Learning; Cuidados de Saúde; Doenças; Médicos; Enfermeiros.Abstract Objective: to analyze the applicability and benefits of Deep Learning in health care. Method: this is a descriptive study, reflective analysis, with articles from 2014 to 2019, published in English and peer-reviewed, in the CAPES Journal Portal, with the search equation (“Deep Learning ”AND (“ Health Care ”OR Health-care OR Healthcare)). The results were presented in figure form followed by descriptive analysis. Results: it is revealed that 15 articles describe the applicability of Deep Learning in the health care area. This article analyzed the use of Deep Learning in different areas related to health care, highlighting the benefits found by the authors of those selected through the literature review. Conclusion: it is suggested the use of Deep Learning in health care in view of the benefits identified in the articles selected as: the prediction of disease stages; precise identification of pathological mutations and support to doctors and nurses in their daily activities. Descriptors: Benefits; Deep Learning; Health Care; Diseases; Physicians; Nurses.ResumenObjetivo: analizar la aplicabilidad y los beneficios del Deep Learning en la atención médica. Método: se trata de un estudio descriptivo, tipo análisis reflexivo, con artículos de 2014 a 2019, publicados en inglés y revisados por pares, en el Portal de la revista CAPES, con la ecuación de búsqueda (“Deep Learning” Y (“Health Care” O Health-care O Healthcare)). Los resultados se presentaron en forma de figura seguida de un análisis descriptivo. Resultados: se revela que 15 artículos describen la aplicabilidad del Deep Learning en el área de la atención médica. Este artículo analizó el uso del Deep Learning en diferentes áreas relacionadas con la atención de la salud, destacando los beneficios encontrados por los autores de los seleccionados a través de la revisión de la literatura. Conclusión: se sugiere el uso de Deep Learning en la atención de la salud en vista de los beneficios identificados en los artículos seleccionados como: la predicción de las etapas de la enfermedad; identificación precisa de mutaciones patológicas y apoyo a médicos y enfermeros en sus actividades diarias. Descriptores: Beneficios; Deep Learning; Cuidados de la Salud; Enfermidades; Médicos; Enfermeros.

scholarly journals Review Of Returning Medical Records In Outpatient Medical Record

2021 ◽  
Vol 1 (1) ◽  
pp. 6-12
Author(s):  
Raden Minda Kusumah ◽  
Jessica Putri Meyliyan
Keyword(s):  
Data Collection ◽  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
Reporting System ◽  
Standard Operating Procedures ◽  
Literature Study ◽  
Standard Operating ◽  
Descriptive Approach

In returning the outpatient medical record file to thesection of the Medical Record Unit, Assembling there was a delay. This is because the return of medical record files has not been carried out according to Standard Operating Procedures, as a result, causing delays in the reporting system. The method used is qualitative using a descriptive approach. Data collection techniques by observation, interviews and literature study. This study aims to determine the return of former medical records of outpatients at Dayeuhkolot Health Center. The results of the study prove that the delay in returning outpatient medical record files at the Dayeuhkolot Health Center with presentations during the 1 week study amounted to 63 or 22% of 285 medical record files. Efforts have been made to disseminate information to all officers related to the efforts made by the person in charge of COVID-19 patients in returning medical record files on time.

scholarly journals SOSIALISASI PELAKSANAAN SISTEM PENGGUNAAN TRACER SEBAGAI PELACAK BERKAS REKAM MEDIS PADA RUMAH SAKIT NAILI DBS PADANG

2019 ◽  
Vol 3 (2) ◽  
pp. 172
Author(s):  
Yastori Yastori
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Fast Time ◽  
Length Of Service ◽  
File Storage ◽  
Quality Of Health Services ◽  
Health Services Needs ◽  
Frequent Problem ◽  
Record Section

Peningkatan mutu layanan kesehatan perlu dilakukan terutama bagi rumah sakit. Rekam medis yang hilang, salah letak, missfile sulit ditemukan dalam waktu yang cepat menjadi permasalahan yang sering terjadi dan mempengaruhi kualitas pelayanan dan menjadi pemicu permasalahan terjadinya berkas rekam medis ganda sehingga mempersulit pengembalian berkas rekam medis sesuai urutan dan mengakibatkan lamanya pelayanan terhadap pasien. Berdasarkan survei pendahuluan, rumah sakit Naili DBS belum menggunakan tracer untuk menandai berkas keluar. Metode yang digunakan adalah observasi dengan wawancara dan diskusi mengenai permasalahan dibagian rekam medis terutama bagian penyimpanan dan pelacakan berkas rekam medis. Pendidikan diberikan melalui sosialisasi pentingnya penggunaan tracer, sistem penggunaan dan tahapan dalam mempersiapkan tracer. Kegiatan ini bertujuan untuk menciptakan budaya  pemanfaatan tracer sebagai kartu pelacak berkas rekam medis keluar dari rak penyimpanan berkas, dilaksanakan pada 11 April 2019 dan berjalan lancar. Hasil yang diperoleh yaitu bahwa di rumah sakit Naili DBS belum menggunakan tracer dan cara pelacakan berkas rekam medis dengan melihat nomor rekam medis pada saat pasein melakukan pendaftaran sehingga membutuhkan waktu yang lebih lama jika dibandingkan dengana adanya tracer. Setelah diadakan sosialisasi ini, bagian rekam medis di rumah sakit Naili DBS memahami akan pentingnya tracer pada bagian rekam medis di rumah sakit.  Kata kunci : Tracer, Rekam Medis, Missfile ABSTRACT Improving the quality of health services needs to be done especially for hospitals. Missing medical records, misplaced, missfiles are difficult to find in a fast time that is a frequent problem that affects the quality of service and triggers problems with the occurrence of multiple medical record files, making it difficult to return the medical record files in order and result in length of service to patients. Based on preliminary surveys, the Naili DBS hospital has not used tracers to mark outgoing files. The method used is observation with interviews and discussions about problems in the medical records section, especially the storage and tracking of medical record files. Education is given through the socialization of the importance of using tracers, usage systems and stages in preparing tracers. This activity aims to create a culture of utilizing tracers as tracking cards for medical record files off the file storage shelves, held on April 11, 2019 and running smoothly. The results obtained are that the Naili DBS hospital has not used tracer and how to track medical record files by looking at the medical record number at the time of registration so that it takes longer than the tracer. After this socialization, the medical records section at Naili DBS Hospital understood the importance of tracers in the medical record section at the hospital. Keywords: Tracer, Medical Record, Missfile

scholarly journals PENGARUH KELENGKAPAN PENGISIAN FORMULIR TRANSFER PASIEN INTERNAL TERHADAP MUTU REKAM MEDIS

2021 ◽  
Vol 10 (2) ◽  
pp. 124-131
Author(s):  
Indar Farwanti Wahyuni
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Random Sampling ◽  
Health Workers ◽  
Sampling Technique ◽  
Simple Random Sampling ◽  
Patient Transfer ◽  
Literature Study ◽  
Number Of Patients

Abstract Internal patient transfer is the process of transferring patients from one room to another in a hospital while still being oriented towards quality and patient safety. The results of the observations showed that the filling of the internal patient transfer form was not optimal so that there were still incomplete forms due to the large number of patients and the weak coordination between health workers. To determine the effect of the completeness of filling out the internal patient transfer form on the quality of medical records. The research method used is quantitative with a descriptive approach. Data collection techniques used are observation, questionnaires and literature study. The sampling technique was simple random sampling technique so as to obtain a sample of 91 internal patient transfer forms. From the results of observations, 22% of the internal patient transfer forms were found that were not completely filled in, especially in the signature and clear name. The two variables have a strong relationship. The effect of the variable completeness of the internal patient transfer form on the medical record quality variable is 90.1% and the remaining 9.9% is influenced by other factors. Based on these studies, it can be concluded that the lack of accuracy and coordination of nurses, doctors and other officers in filling out internal patient transfer forms so that this affects the quality of medical records in the aspect of accuracy. Keyword : Completeness, Internal Patient Transfer Form, Medical Record Quality   Abstrak Transfer pasien internal merupakan proses pemindahan pasien dari satu ruangan ke ruangan yang lain di dalam satu rumah sakit dengan tetap berorientasi pada mutu dan keselamatan pasien. Hasil observasi menunjukkan bahwa belum optimalnya pengisian formulir transfer pasien internal sehingga masih terdapat formulir yang tidak lengkap disebabkan oleh faktor dari banyaknya pasien dan lemahnya koordinasi antara tenaga kesehatan. Untuk mengetahui pengaruh kelengkapan pengisian formulir transfer pasien internal terhadap mutu rekam medis. Metode penelitian yang digunakan yaitu kuantitatif dengan pendekatan deskriptif. Teknik pengumpulan data yang digunakan adalah observasi, kuesioner dan studi pustaka. Teknik pengambilan sampel adalah teknik simple random sampling sehingga memperoleh sampel sebanyak  91 formulir transfer pasien internal. Dari hasil observasi ditemukannya formulir transfer pasien internal yang belum terisi lengkap sebanyak 22% terutama pada tandatangan dan nama jelas. Kedua variabel memiliki hubungan yang kuat. Pengaruh variabel kelengkapan formulir transfer pasien internal terhadap variabel mutu rekam  medis sebesar 90,1% dan sisanya 9,9% dipengaruhi oleh faktor lain. Berdasarkan penelitian tersebut dapat disimpulkan bahwa kurangnya ketelitian dan koordinasi perawat, dokter dan petugas lain dalam pengisian formulir transfer pasien internal sehingga hal ini mempengaruhi mutu rekam medis pada aspek keakuratan. Kata kunci: Kelengkapan, Formulir Transfer Pasien Internal, Mutu Rekam Medis

scholarly journals ANALISIS KETIDAKLENGKAPAN REKAM MEDIS RAWAT INAP DI RUMAH SAKIT

2021 ◽  
Vol 1 (2) ◽  
Author(s):  
NEVITA RAHMAWATI NEVITA
Keyword(s):  
Literature Review ◽  
Medical Record ◽  
Medical Records ◽  
Inpatient Treatment ◽  
Hospital Records ◽  
Hospital Medical ◽  
Treatment Step

ABSTRAK Latar Belakang : Analisis ketidaklengkapan pengisian rekam medis sangat diperlukan, guna mengetahui seberapa besar angka ketidaklengkapan pengisian catatan medis (AKLPCM) di RSU Mitra Medika pada tahun 2018. Ditemukan bahwa dari seluruh berkas rekam medis pasien pulang dari rumah sakit terdapat 13.279 berkas terdapat ketidaklengkapan pengisian sebanyak 7,66% (1.017) berkas. Salah satu diantaranya adalah ketidaklengkapan pengisian resume medis, ketidaklengkapan pengisian identitas pasien sebanyak 5 formulir (16,6%), anamnese 4 (13,3%), pemeriksaan fisik 2 (6,6%), diagnosa 1 (6,6%), pemeriksaan penunjang 4 (13,3%) dan tindakan medis sebanyak 2 formulir (6,6%). Tujuan : Tujuan dari literature review ini adalah untuk untuk menganalisis Ketidaklengkapan Rekam Medis Rawat Inap Di Rumah Sakit. Metode : penelitian ini menggunakan desain literature review yaitu uraian tentang teori, bahan dan isi penelitian yang mengkaji tentang ketidaklengkapan rekam medis rawat inap di rumah sakit berdasarkan literature yang di review. Hasil : berdasarkan 8 jurnal di jelaskan bahwa Pengisian ketidaklengkapan rekam medis dari hasil penelitian menunjukan bahwa tidak lengkap masih tinggi pada angka 100% menandahkan kejadian ketidaklengkapan masih sering terjadi dan tidak sesuai dengan standart kelengkapan berkas rekam medis. Kesimpulan : Mengadakan monitoring evaluasi minimal 1 minggu sekali, membuat tim monitoring kelengkapan berkas  untuk memantau pelaksanaan rekam medis di rumah sakit Kesimpulan : Mengadakan monitoring evaluasi minimal 1 minggu sekali, membuat tim monitoring kelengkapan berkas  untuk memantau pelaksanaan rekam medis di rumah sakit   Kata Kunci : Ketidaklengkapan rekam medis, Rawat Inap, Langkah meningkatkan kelengkapan     ABSTRACT Background: incompleteness analysis of medical record-charging is essential, in order to see how high the incompleteness of medical records (aklpcm) in medika's partner-general general in 2018. It was found that from all the records of patients returning from the hospital there were 13,279 files of this incompleteness charging 7.66% (1,017) of the files. One is the incompleteness of medical resumes, the incompleteness of the patient's 5 forms (166%), anamnese 4 (13.3%), physical 2 (6.6%), diagnostic 1 (6.6%), 4 (13.3%) and 2 forms (6.6%) medical action. Purpose: the purpose of this literature review is to analyze the incompleteness of hospital hospital medical records. Method: the study USES the design literature review, which is a description of theory, the material and content of the study that deals with the incompleteness of medical hospital records based on the literature contained in the review. Results: according to 8 journals explain that the application of incompleteness of medical records from research shows that incomplete remains high at 100% indicating an occurrence of incompleteness is still frequent and incompatible with the standard for a medical record file. Conclusion: install a minimum evaluation monitoring once a week, creating a file monitoring team to monitor medical records at the hospital.   Keywords: of incompleteness medical records, inpatient treatment, step up completeness  

Electronic Medical Record as Literature Study

2022 ◽  
Vol 2 (1) ◽  
pp. 45-51
Author(s):  
Yuli Mardi
Keyword(s):  
Human Resources ◽  
Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Health Care Services ◽  
Scientific Journal ◽  
Data Entry ◽  
Health Facilities ◽  
Literature Study ◽  
Planning Stage

Background: Medical records can be created manually or electronically. In the world of health, the development of information and communication technology is currently affecting health care services as a whole, including the implementation of electronic medical records. The application of electronic medical records must go through a careful planning stage, this is because electronic medical records involve many parties in health facilities and and require a lot of costs. For this reason, a comprehensive study of electronic medical records is needed. One way is to conduct a literature study of several articles related to the electronic medical record.Methods: In conducting this research, the literature review method was used, where the search for articles was not carried out systematically, but the scientific journal articles reviewed were selected by the researcher on one research topic, and selected based on the knowledge and experience possessed by the researcher (traditional review).Results: In this study, 7 articles were reviewed related to electronic medical records. There are some similarities in terms of benefits or obstacles in the application of electronic medical records in health facilities. Among the benefits of electronic medical records are the efficiency of using paper/medical record files, efficiency in the use of space/storage media, time efficiency in searching data and distributing medical record data, efficiency of human resources in finding medical record files and being able to detect errors in data entry. While some of the common obstacles to implementing electronic medical records in health facilities are the unpreparedness of officers at health facilities, so it takes time for socialization and training of human resources, problems with the network, lack of IT resources at health facilities that specifically handle electronic medical records, high implementation costs. expensive (hardware software) and there is no legal umbrella.Conclusions: There is a need for comprehensive research using the semantic review method of articles related to electronic medical records, so that the results can be used as a reference for health facilities in implementing electronic medical records. Thus, it is hoped that the migration and implementation process from manual medical records to electronic medical records can be carried out as expected.

scholarly journals APLIKASI RETENSI REKAM MEDIS MENGGUNAKAN MICROSOFT ACCESS

2021 ◽  
Vol 5 (1) ◽  
pp. 110-117
Author(s):  
Alfauzain Alfauzain ◽  
Berly Nisa Srimayarti ◽  
Dian Novita ◽  
Muhammad Ridwan
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Storage Period ◽  
Database Management System ◽  
Flow Diagram ◽  
Literature Study ◽  
Web Based ◽  
Server Side ◽  
Microsoft Access ◽  
Table Data

Medical record retention is a system that regulates the storage period for medical record files. Medical records officers are also involved in destroying medical records including in the retention process. The slow retention process resulted in a large number of medical record files piling up in storage racks so that the medical record space became narrow. Developing medical record retention applications using Microsoft Access. This research method is carried out by conducting a Literature Review with the Literature Study method. The data sources in this study were 3 journals by looking at the inclusion and exclusion categories. Analyze data in terms of similarities, inequalities, views, compare and summaries. The results of 3 literature study journals are medical record retention applications made with web-based methods and web-based imaging. The system design uses Flowmap, DFD (Data Flow Diagram) and ERD (Entity Relationship Diagram) and is implemented with the Microsoft Visual Basic.Net programming language and Microsoft Access as a DBMS (Database Management System). The medical record retention application is very helpful for officers in separating active and inactive medical record files, which are equipped with menus according to user needs. It is hoped that the next researchers on several related articles, further research is needed on designing applications using table data with server side processing.

scholarly journals Tinjauan Literatur: Faktor-Faktor Penyebab Kelengkapan Pengisian Rekam Medis Rawat Inap Rumah Sakit

2020 ◽  
Vol 3 (2) ◽  
pp. 46-52
Author(s):  
Putu Adiz Siwayana ◽  
Ika Setya Purwanti ◽  
Putu Ayu Sri Murcittowati
Keyword(s):  
Quality Of Service ◽  
Literature Review ◽  
Medical Record ◽  
Medical Records ◽  
Health Workers ◽  
Medical Personnel ◽  
Google Scholar ◽  
Incomplete Filling ◽  
Evaluation And Monitoring

Every health facility, whether it is primary, secondary, tertiary, is required to maintain medical records in order to achieve administrative order. Incomplete (incomplete) medical records will affect the service process provided by health workers and have an impact on the quality of service of a hospital. This study aims to determine the factors causing the incomplete filling of inpatient medical records. This study uses a literature review method. The strategy in searching literature reviews is using Google Scholar. In the search phase, articles are limited to publications from 2015-2020. The keywords used are the factors causing incomplete medical record filling. The search results obtained 10 articles and then 5 articles were taken. The results of the literature review show that the factors causing the incompleteness of filling in medical records as a whole can be seen from the lack of knowledge, motivation and awareness of medical personnel about medical records. The meeting as a means of communication between caregivers and management has not yet been implemented to discuss evaluation and monitoring as well as sanctions for officers who do not complete medical records. lack of socialization on filling out medical records. Unsystematic arrangement of medical record forms. Limited availability of funds or budget to support medical record service activities. Conclusion Hospitals need to pay attention to the factors causing the incompleteness of filling in medical records so that filling in medical records is complete according to standards. So that the quality of service, especially the quality of patient medical records.AbstrakSetiap fasilitas kesehatan baik tingkat primer, sekunder, tersier wajib menyelenggarakan rekam medis agar tercapainya tertib administrasi. Ketidaklengkapan (Incomplete) rekam medis akan berpengaruh terhadap proses pelayanan yang diberikan oleh petugas kesehatan dan berdampak pada kualitas pelayanan suatu rumah sakit. Penelitian ini bertujuan untuk mengetahui faktor penyebab ketidaklengkapan pengisian rekam medis rawat inap. Penelitian ini menggunakan metode literatur review. Strategi dalam pencarian literatur review menggunakan Google Scholar. Pada tahap pencarian artikel dibatasi terbitan dari tahun 2015-2020. Kata kunci yang digunakan adalah Faktor Penyebab ketidaklengkapan pengisian rekam medis. Hasil penelusuran artikel didapatkan 10 artikel dan selanjutnya diambil 5 artikel. Hasil dari literatur review didapatkan faktor penyebab ketidaklengkapan pengisian rekam medis secara keseluruhan, penyebabnya dapat dilihat dari kurangnya pengetahuan, motivasi dan kesadaran dari petugas rekam medis tentang rekam medis. Belum terlaksananya rapat sebagai wadah komunikasi antara pemberi asuhan dan manajemen yang membahas evaluasi dan monitoring serta sanksi bagi petugas yang tidak mengisi rekam medis dengan lengkap. kurangnya sosialisasi pengisian rekam medis. Susunan formulir rekam medis yang tidak sistematis. Terbatasnya ketersediaan dana atau anggaran untuk mendukung kegiatan pelayanan rekam medis. Kesimpulan Rumah sakit perlu memperhatikan  faktor penyebab ketidaklengkapan pengisian rekam medis sehingga pengisian rekam medis menjadi lengkap sesuai dengan standar. Sehingga  mutu dari pelayanan terutama mutu rekam medis pasien.

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