PENGARUH LAMA RAWAT DAN TINGKAT KEPARAHAN PENYAKIT TERHADAP KUALITAS RESUME MEDIS PADA PASIEN JKN RAWAT INAP KASUS SEPSIS DI RSUD BUDHI ASIH

Authors

  • Rien Mutia Rahmadilla Author
  • Husni Abdul Muchlis Author
  • Hosizah Author
  • Yati Maryati Author
  • Sigit Sugiarto Author

DOI:

https://doi.org/10.54314/jssr.v9i5.7271

Keywords:

National Health Insurance (JKN), Medical Resume Quality, Sepsis, Length of Stay, Disease Severity

Abstract

A medical summary is a synopsis of the medical services provided to a patient. However, at Budhi Asih Regional General Hospital (RSUD), 228 files (76%) were found to have issues regarding medical aspects, reflecting the low quality of medical summaries for sepsis patients. This study aimed to analyze the influence of length of stay and disease severity on the quality of medical summaries for hospitalized JKN (National Health Insurance) patients with sepsis at RSUD Budhi Asih. A quantitative approach with a cross-sectional design was employed, covering the period from October to December 2025. The sample consisted of 183 medical records selected using total sampling. Data were collected through a review of medical record documents. The results showed that 147 files (80.3%) fell into the low-quality category, while 36 files (19.7%) were of high quality. The average length of stay was 8.09 days with a variation of 4.31 days, while disease severity was predominantly Severity Level III, affecting 146 patients (79.8%). Logistic regression analysis revealed that length of stay and disease severity simultaneously had a significant effect on medical summary quality (p=0.004). Individually, length of stay did not have a significant effect (p=0.615), whereas disease severity did (p=0.001). The Nagelkerke R² value of 0.094 indicates that these two variables explain 9.4% of the variation in medical summary quality. Hospitals are advised to pay greater attention to the quality of medical summaries, particularly for patients with prolonged hospital stays and high disease severity.

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References

Hess, P.C. Clinical Documentation Improvement. American Health Information Management Association, Chicago, IL (2015).

Alruwaili MA, Alanazi ASM, S YD, Alharthi FMH, Almurayhil NMM, Alharbi AM, et al. Letters in High Energy Physics The Importance of Accurate Documentation in Clinical Settings and Hospital Management. 2023;2023(3):1013–27.

Duta U, Surakarta B. ANALISIS KELENGKAPAN PENGISIAN FORMULIR RESUME MEDIS. 2022;(2011):225–30.

Ulum M. ANALISIS PENYEBAB KETIDAKLENGKAPAN PENGISIAN RESUME. 9831.

Inti S, Viridula EY, Damayanti R, Amran AR. Correlation between Medical Record Completeness and Inpatient Length of Stay Efficiency Based on Secondary Data from Vertical Hospitals. 2025;01(2):1–11.

Xiang J, Durance PW, Griffes LC, Chen Y, Bakshi RR. Measuring case severity : a novel tool for benchmarking and clinical documentation improvement. BMC Health Serv Res [Internet]. 2022;1–9. Available from: https://doi.org/10.1186/s12913-022-07935-1

Binarti I, Fitriyana FD. Analysis of Incomplete Medical Record Filling in Indonesia. 2022;4(1):347–57.

Sari LM, Farhan M. Tinjauan Kelengkapan Isi Rekam Medis Pada Formulir Resume Medis Pasien Rawat Inap Kasus Bedah Digestive Di Rsud Siti Fatimah Provinsi Sumatera Selatan. 2022;(November):0–5.

Kasim F. Faktor-Faktor yang Mempengaruhi Kualitas Pelayanan Rekam Medis Factors Affecting the Quality of Medical Record Services. (c):457–65.

Di M, Majalaya R, Sari I. Pengaruh Kelengkapan Formulir Resume Medis Rawat Inap Terhadap Mutu Rekam. 2023;15(2):1–11.

Murtiningrum R, Kusnanto H, Kesehatan K, Kedokteran F, Masyarakat K, Manajemen D, et al. Kualitas Resume Medis ( Discharge Summary ) Pada Pasien Rawat Inap JKN di RSUD Dokter Soedarso Propinsi Kalimantan Barat. 2019;4(1).

Selatan KT. TINJAUAN KELENGKAPAN PENGISIAN RINGKASAN PULANG RAWAT INAP DI RUMAH SAKIT UMUM KOTA TANGERANG SELATAN. 2025;04(1):17–30.

Wahyudin RF, Pamungkas TS, Hidayati M, Medis R, Kesehatan I, Ganesha PP. ANALISA KETIDAK LENGKAPAN PENGISIAN RINGKASAN PASIEN. 2021;1(7):847–57.

Permenkes. Peraturan Menteri Kesehatan RI No 24 tahun 2022 tentang Rekam Medis. Peratur Menteri Kesehat Republik Indones Nomor 24 Tahun 2022. 2022;151(2):1–19.

Sholeh A. Analisis Kelengkapan Pengisian Ringkasan Pulang Terhadap Kelancaran Klaim Badan Penyelenggaraan Jaminan Sosial Kesehatan di Rumah Sakit PTPN VIII Subang. 2023;2(1):1–6.

Fanny N. Kualitas Dokumen Rekam Medis Rawat Inap Berdasarkan Analisis Kualitatif. 2020;10(2):28–33.

Indriaty J, Km S. Pengaruh Pelatihan Manajemen Rekam Medis Terhadap Kualitas Dokumentasi Medis di Pelayanan Kesehatan The Effect of Medical Record Management Training on the Quality of. 2023;5:1–3.

Ebbers T, Kool RB, Smeele LE, Dirven R, Besten CA Den, Karssemakers LHE. The Impact of Structured and Standardized Documentation on Documentation Quality ; a Multicenter , Retrospective Study. J Med Syst [Internet]. 2022;3–9. Available

Safirah N, Abdul B, Rizal AM. Understanding the Problems in Documenting Clinical Documentations : A Conceptual Analysis. 2025;15(11):606–15.

Koding A, Khusus P, Tahun B, Tahun B, Tahun B, Tahun B, et al. No Title.

Siada NB, Juanita RA. Faktor-Faktor yang Mempengaruhi Lama Rawat Inap Pasien Dengue Hemorrhagic Fever di Salah Satu Rumah Sakit Umum Daerah di Bali 2025;11(1):40–7.

Simond ML, Arif Y, Murni D, Keperawatan M, Andalas U, Melitus D. KARAKTERISTIK LENGTH OF STAY DAN READMISSION PASIEN. 2023;7(2):169–76.

Muchlis HA, Qomarania WZ, Nurmalasari M, Cyntia A, Kurniawati D, Widya B. Length of Stay Patterns and Their Relation to Coding Accuracy Polanya Lama Tinggal Pasien dan Hubungannya dengan Akurasi Koding. 2025;9:86

Indonesian P, Base C, Pelaksanaan D, Kesehatan J, Ina-cbg CBG. Peraturan menteri kesehatan republik indonesia nomor 26 tahun 2021 tentang pedoman. 2021;

Neri PM, Volk LA, Samaha S, Pollard SE, Williams DH, Fiskio JM, et al. Relationship between documen- tation method and quality of chronic disease visit notes.

Report O. THE INFLUENCE OF SEAMLESS AND COMPLETENESS DISCHARGE SUMMARY FILLING TO SUITABILITY OF SEVERITY LEVEL IN TERTIARY REFERRAL HOSPITAL. 2020;23(Suppl 1).

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Published

2026-10-13

How to Cite

PENGARUH LAMA RAWAT DAN TINGKAT KEPARAHAN PENYAKIT TERHADAP KUALITAS RESUME MEDIS PADA PASIEN JKN RAWAT INAP KASUS SEPSIS DI RSUD BUDHI ASIH. (2026). JOURNAL OF SCIENCE AND SOCIAL RESEARCH, 9(5), 8048-8061. https://doi.org/10.54314/jssr.v9i5.7271

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