THE EFFECT OF COMPLETENESS OF INFORMED CONSENT IN INPATIENT ROOMS ON THE QUALITY OF MEDICAL RECORDS AT RSAD TK. II UDAYANA

Abstract

The completeness of filling in the informed consent sheet in the medical record file is very important because it will affect the legal aspects of the medical record and the quality of the medical record so that filling in the complete data in the informed consent sheet needs to be done with maximum implementation. This study aims to determine the effect of completing the Informed Consent form in the inpatient room on the quality of medical records at RSAD Tk. II Udayana, Bali. The research method used is quantitative research with a cross sectional approach. The data collection technique used is by taking questionnaires, observation, checklists and case studies. The sampling technique was random sampling technique with a sample of 33 informed consents and 33 respondents. Based on the research results, the influence of completeness of informed consent in the inpatient room on the quality of medical records at RSAD Tk. II Udayana by 75%. The problems that occur are: (1) There are still incomplete informed consent forms, (2) There are unclear written actions, (3) Delays in returning incomplete medical records to the KLPCM department. The suggestions given are: (1) Conduct socialization on fixed procedures regarding filling out informed consent, (2) Medical records officers and other health workers must continue to remind each other about filling in complete informed consent, (3) Conduct training regarding the implementation of filling out informed consent forms.