PENGARUH REDESAIN FORMULIR REKAM MEDIS RAWAT INAP TERHADAP KELENGKAPAN PENGISIAN REKAM MEDIS DI RS BRAYAT MINULYA SURAKARTA

CAHYO HADI PREMONO, Dr. Luftan Lazuardi, M.Kes, Phd.

2018 | Tesis | MAGISTER ILMU KESEHATAN MASYARAKAT

Latar Belakang: Kelengkapan Pengisian Dokumen Rekam Medis Rumah Sakit Brayat Minulya Surakarta tahun 2014 adalah 60,3%, tahun 2015 (63,6%)dan tahun 2016 (73,8%). Standar Kelengkapan pengisian rekam medis sebesar 100%. Formulir Rekam Medis Rumah Sakit Brayat Minulya Surakarta berjumlah banyak. Judul formulir rekam medis Rumah Sakit Brayat Minulya Surakarta sekarang ini berjumlah 104 judul formulir. Tujuan: Melakukan redesain formulir rekam medis rawat inap untuk meningkatkan kelengkapan pengisian rekam medis ruang keperawatan Yosep. Metode: Penelitian dilakukan dengan metode action research. Penelitian dilakukan di ruang perawatan dewasa Yosep Rumah Sakit Brayat Minulya Surakarta. Rumah Sakit Brayat Minulya selama 3 minggu. Populasi obyek penelitian ini adalah seluruh dokumen rekam medis rawat inap pasien di keperawatan dewasa ruang Yosep. Hasil dan Pembahasan: Anatomi formulir dan kemudahan formulir rekam medis lebih baik sebelum ujicoba dibanding dengan setelah ujicoba dengan melihat mean sebelum ujicoba < mean setelah ujicoba. Kelengkapan pengisian rekam medis rawat inap terjadi penurunan dari sebelum redesain (49% ) menjadi sesudah redesain (33%). Kesimpulan dan Saran: Tenaga kesehatan masih terbiasa dengan formulir rekam medis rawat inap sebelum redesain. Redesain formulir rekam medis rawat inap perlu dilakukan proses perbaikan lagi meliputi fisik formulir rekam medis dan anatomi formulir rekam medis.

Background Level of completion in fulfilling the medical record documents at Brayat Minulya Hospital, Surakarta, was 60.3% in the year of 2014, then increased to 63.6% in 2015, after that 73.8% in 2016. Standard of completion in fulfilling the medical record is 100%. There areas many as 104 titles of medical record forms at Brayat Minulya Hospital, Surakarta Objectives The objective is to redesign the forms of medical record for inpatient in adult care room, Yosep Room, at Brayat Minulya Hospital, Surakarta. Method This research is implemented by using the method of action research. The research is carried out in adult care room, Yosep Room, at Brayat Minulya Hospital, Surakarta for three weeks. The population of objects in this research is the whole medical record documents for inpatient in adult care room, Yosep Room, at Brayat Minulya Hospital, Surakarta Result and Discussion Anatomy of the forms and easyness in fulfiling the forms of medical records are better before the experiment compared to after the experiment. It is shown by the fact that the mean before the experiment < the mean after the experiment. There is a decrease of completion in fulfilling the medical record from 49% before the redesigning to 33% after the redesigning. Conclusion and Suggestion Medical officials are still accustomed to the forms of medical records for inpatients before being redesigned. Redesigning the forms of medical records still becomes a necessity, covering the physic of the medical record forms and the anatomy of the medical record forms

Kata Kunci : rekam medis, kelengkapan rekam medis, redesain formulir rekam medis, medical record, completion of medical record, redesigning the medical record form