Laporkan Masalah

DESAIN MAP DAN FORMULIR REKAM MEDIS DI KLINIK ISTIAZAH BANTUL

DIAN SEKLI MAHARDIKA, Dian Budi Santoso, S.K.M., M.P.H.

2018 | Tugas Akhir | D3 REKAM MEDIS SV

Latar Belakang: Klinik Istiazah Bantul telah melaksanakan pendokumentasian rekam medis, tetapi terdapat kekurangan.Hasil pemeriksaan gigi didokumentasikanke dalam satu lembar pemeriksaan umum (tercampur), sehingga dokter gigi kesulitan dalam melakukan pemeriksaan khususnya pasien kontrol, dokter gigi harus mencatat pemeriksaan dan lokasi gigi sakit seluruh pasien di catatan pribadi dokter gigi tersebut. Selain itu Klinik Istiazah Bantul belum memiliki formulir persetujuan tindakan medis.Formulir persetujuan tindakan medis merupakan formulir yang seharusnya ada di sebuah fasilitas kesehatan karena formulir ini berfungsi sebagai alat bukti perlindungan hukum untuk dokter, fasilitas kesehatan, maupun pasien jika suatu hari nanti terdapat hal yang tidak diinginkan dalam melakukan tindakan medis. Map yang ada terlalu kecil sehingga sering terjadimisfileddan memperlambat proses pelayanan. Formulir rawat jalan juga masih perlu diperbaiki kerena belum terdapat identitas klinik, identitas formulir serta jarak antar kolom yang sempit yang menyulitkan dalam penulisan. Tujuan : Menghasilkan rancangan map rekam medis, formulir rawat jalan, formulir persetujuan tindakan medis dan formulir gigi dengan menekankan aspek isi, fisik, dan anatomi yang sesuai dengan kebutuhan pengguna. Metode : Pembuatan rancangan map dan formulir rekam medis ini menggunakan metode dan tahapan pengembangan formulir sesuai dengan RCH Forms Commitee(2006). Hasil: Hasil dari perancangan ini berupa dua alternatif desain untuk map rekam medis, formulir rawat jalan, formulir gigi, dan formulir persetujuan tindakan medis. Setelah melalui proses pengusulan terpilihlah map rekam medis alternatif 1, formulir rawat jalan alternatif 2, formulir persetujuan tindakakan alternatif 1 dan formulir gigi alternatif 2, dengan mempertimbangkan desain alternatif terpilih dan adanya saran perbaikan pengguna diperolehlah rancangan akhir. Kesimpulan: Telah dihasilkan map rekam medis, formulir rawat jalan, formulir gigi, dan formulir persetujuan tindakan medis sesuai teori dan keutuhan pengguna.

Background: Klinik Istiazah Bantul has performed documentation of medical records, but there is no specific form that is used to record the dental examination results. The results of the examination are documented and mixed into a general inspection form , so the dentist has a difficulty in performing the examination especially for the follow up patients, the dentist should record the examination and location of the patient's diseased teeth in the dentist's personal record. Besides, Klinik Istiazah Bantul does not have an informed consent form. Every healthcare facilities should have an informed consent because informed consent serves as a legal proof of protection for doctors, healthcare facilities and patients if there is any unforseeable occurrence in the medical treatment. The map and the existing medical record form are too small. This leads to frequent misfiles resulting in longer service processes. Outpatient forms also need to be improved because there is no clinic’s identity, form’s identity and the narrow column spacing makes the user difficult to write down the examination record. Objective :Creating the medical record maps, outpatient form, informed consent form and dental form emphasizing the content, physical, and anatomical aspects to conform the users need Methods: The design of these maps and medical record forms uses the method and steps of forms design according to RCH Forms Committee (2006). Result: The results of this design are two alternative designs for medical record maps, outpatient forms, dental forms, and informed consent forms. After the selection process, the user selected medical record maps first alternative, outpatient forms second alternative, informed consent form first alternative and also dental forms second alternative. Considering the selected alternative designs and suggestions for improvement from user, the final design is resulted. Conclusion: It is concluded that a medical record map, outpatient form, dental form, andinformed consent form have been designed according to the theory of medical records design and appropriate with the user needs.

Kata Kunci : perancangan formulir, map rekam medis, formulir gigi, formulir rawat jalan, formulir persetujuan tindakan medis, klinik/ form design, medical record map, dental form, outpatient form, clinic


    Tidak tersedia file untuk ditampilkan ke publik.