Overview of the Design and Completion of the Admission and Discharge Summary Form at Harapan dan Doa Regional General Hospital, Bengkulu City

Abstract

Medical record form design involves designing a medical record form tailored to the needs of the healthcare workers who will complete it. The importance of completeness in completing the medical record is also demonstrated by its use as an indicator of service quality. Incomplete medical records can impact doctors, other healthcare workers, and other stakeholders. Several aspects must be considered in form design, including the anatomical aspects, including the heading, introduction, instructions, body, and closing. Understanding the design and completion of the admission and discharge summary form. The descriptive method explains the problem in detail based on available data and facts. Researchers directly observed the admission and discharge summary forms and explored staff compliance with the completeness of the forms. Anatomically, the admission and discharge summary forms were found to be inconsistent in the heading section, lacking a logo, revision code, and page number. Instructions are not yet available, the left margin of the body is too narrow, namely 0.9 cm, causing data information to often be lost if the form is perforated to be inserted into the folder, the cover is already there but only has a signature and no clear name. Of the 7 officers who filled out the entry and exit sheets, 4 (57.1%) officers complied with filling out the entry and exit sheet, and 3 (42.8%) officers did not comply with filling out the entry and exit sheet.