Resume medis merupakan ringkasan dari seluruh masa perawatan dan pengobatan pasienyang wajib diisi lengkap oleh Dokter Penanggung Jawab Pasien (DPJP) dalam 1x24 jamsetelah pasien pulang. Penelitian ini dilakukan untuk menganalisis kelengkapan dan ketepatanwaktu pengisian resume medis menggunakan pendekatan sistem. Jenis penelitian kualitatifdigunakan untuk mendapatkan gambaran input dan transformasi melalui wawancara mendalamserta telaah dokumen, yang kemudian diperkuat dengan penelitian kuantitatif untukmendapatkan gambaran output, melalui observasi dan telaah formulir. Terdapat 61 sampelformulir resume medis dengan menggunakan perhitungan total sampling. Hasil penelitianmenunjukkan bahwa persentase resume medis yang termasuk ke dalam kategori terpenuhilengkap hanya 16,4%, sedangkan dari segi ketepatan waktu ditemukan hanya 45,9% pengisianresume medis yang termasuk ke dalam kategori tepat waktu. Rata-rata waktu pengisian resumemedis yaitu 32,3 jam. Kelompok item identitas pasien dan data perawatan memiliki distribusiketerisian terendah, sedangkan distribusi keterisian tertinggi terdapat pada kelompok item datamedis dan data autentikasi. Masih terdapat perbedaan pengetahuan dalam pengisian resumemedis, kurangnya motivasi dokter, evaluasi format formulir yang belum rutin dilaksanakan,adanya inkonsistensi kebijakan rumah sakit, belum ada sistem reward dan punishment untukdokter, belum ada diklat khusus resume medis, terdapat perbedaan persepsi mengenai alurpengisian resume medis, serta konflik dalam komunikasi interpersonal.Kata Kunci: Kelengkapan, Ketepatan Waktu, Resume Medis, Ringkasan Pulang

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Discharge summary is a resume of all patient care and treatment periods that must befilled in completely by the doctor in charge within 1x24 hours after the patient was declareddischarged. This study discuss about the completeness and the timeliness of filling in dischargesummary by using the system approach. This research is a qualitative study to obtain input andtransformation through in-depth interviews and review of hospital documents, then reinforcedwith quantitative research to get an overview of the output, through observation and study ofdischarge summary forms. Obtained 61 discharge summary forms used as research samples byusing the calculation of total sampling. The results showed that the percentage of dischargesummary included in the category fulfilled was only 16.4%, while in terms of timeliness it wasfound that only 45.9% of filling discharge summary were included in the appropriate timeaccuracy category. The average time needed for a doctor to get a discharge summary is 32.3hours. The patient identity and the nursing data items group had the lowest filling distribution,while the highest filling distribution was in the medical data and data authentication group.There are still differences in knowledge in filling out discharge summary, lack of motivationof the doctors, form formats evaluation that have not been carried out routinely, there is noreward system, punishment system and special training for discharge summary, differences inperceptions regarding the flow of the discharge summary filling process, and the discovery ofconflicts related to communication.Keywords: Completeness, Timeliness, Discharge Summary, Medical Resume.