KELENGKAPAN PENGISIAN FORMULIR ASESMEN AWAL MEDIS RAWAT INAP BANGSAL VIP DI RSUD KABUPATEN TEMANGGUNG

QONITIN, Dr. dr. Wahyudi Istiono, M.Kes

2017 | Tugas Akhir | D3 REKAM MEDIS SV

ABSTRAK Latar Belakang: Rekam Medis adalah bagian penting dalam pelayanan pasien serta dapat menggambarkan mutu pelayanan yang diberikan. Rekam medis berkualitas baik jika diisi lengkap. Di RSUD Kab. Temanggung, pengisian rekam medis dari Bangsal VIP masih tinggi ketidaklengkapannya. Salah satu rekam medis yang sering tidak terisi lengkap adalah formulir asesmen awal medis rawat inap. Tujuan: Penelitian ini bertujuan untuk mengetahui kelengkapan pengisian formulir asesmen awal medis rawat inap dari bangsal VIP dengan mengetahui kebijakan, persentase kelengkapan dari hasil analisis kuantitatif serta cara pengendalian ketidaklengkapannya oleh subunit assembling di RSUD Kabupaten Temanggung. Metode: Jenis penelitian yang digunakan pada penelitian ini adalah deskriptif dengan pendekatan kualitatif. Rancangan penelitian dengan studi kasus. Pengumpulan data dilakukan dengan wawancara, observasi dan studi dokumentasi. Hasil: Di RSUD Kabupaten Temanggung sudah ada kebijakan mengenai kelengkapan pengisian fromulir asesmen awal medis rawat inap yang tertulis dalam bentuk SPO, Indikator Mutu dan Buku Pedoman. Dari hasil analisis kuantitatif terhadap 120 formulir asesmen awal medis dari Bangsal VIP didapatkan hasil kelengkapan pada review identifikasi pasien 91,90%, review laporan penting 47,69%, review autentikasi sebesar 35,83% dan pada review pendokumentasian yang benar sebesar 62,20%. Proses pengendalian ketidaklengkapan bagian assembling dengan mengembalikan berkas ke dokter penanggungjawab pasien di bangsal/klinik rawat jalan. Kesimpulan: Kebijakan kelengkapan pengisian asesmen awal medis sudah sesuai dengan peraturan pemerintah dan teori yang ada. Pengisian formulir asesmen awal medis rawat inap dari Bangsal VIP banyak yang belum lengkap sesuai dengan kebijakan. Pengendalian ketidaklengkapan oleh bagian assembling sudah sesuai dengan kebijakan namun belum bisa terlaksana menyeluruh. Kata Kunci: Formulir Asesmen Awal Medis, Kelengkapan, Kebijakan, Analisis Kuantitatif, Assembling.

ABSTRACT Background: Medical Record is one of the most important parts in patient service which is also reflects the quality of hospital service. The Medical Record is considered to be a good if it is completely filled. In Temanggung Hospital, specifically in VIP Wards, there found many forms that are not completely filled. Part of the medical record that mostly left blank is the preliminary assessment in patient departement. Objective: This study aims to identify the completeness of preliminary assessment form-filling in patient departement of VIP wards Temanggung Hospital by understanding its policy, its completeness based on quantitative analysis result, and its method in controlling the uncompleted document done by the assembling subunit of Temanggung Hospital. Method: Qualitative method is utilized since the study focuses on the description of the case. While the research plan were conducted in case studies. The data itself are collected by interviewing, observing and document investigating. Result: There has been applied some policy concerning the completeness of the preliminary assessment form-filling in patient departement written in Standard Operating Procedure (SOP) Quality Indicator, and Manual Book. The study of 120 medical preliminary assessment form from VIP Ward using quantitative analysis shows the rate of form-filling completeness, as follows; patient identification review 91,90%, important report review 47,69%, authentication review 35,83%, and the correct documenting 62,20%. The assembling subunit tried to complete these uncompleted documents by returning those to the doctors in charge in each ward/clinic. Conclusion: The policy of medical preliminary assessment form-filing has already in line with government regulation and theories that support. There are found many uncompleted medical preliminary assessment forms in VIP Wards which is inaccordance with government regulation. To solve this problem, The Assembling Department has taken some action that fit the policy, but it cannot be applied thoroughly yet. Keywords: Medical Preliminary-assessment Form, Completeness, Policy, Quantitative Analysis, Assembling.

Kata Kunci : Formulir Asesmen Awal Medis, Kelengkapan, Kebijakan, Analisis Kuantitatif, Assembling