PERANCANGAN STANDAR PROSEDUR OPERASIONAL (SPO) PELAKSANAAN REKAM MEDIS DALAM RANGKA PERSIAPAN AKREDITASI KLINIK DI KLINIK PRATAMA KORPAGAMA UGM

MARISA KHULSUM P P, Dr.dr.Wahyudi Istiono,M.Kes

2018 | Tugas Akhir | D3 REKAM MEDIS DAN INFORMASI KESEHATAN

Latar Belakang: SPO merupakan salah satu aspek penilaian dokumen akreditasi. Klinik Pratama Korpagama UGM hanya mempunyai 5 SPO. Kelima SPO tersebut belum sesuai Format akreditasi FKTP (2017). Ditinjau dari kesiapan SPO pelaksanaan rekam medis, Klinik belum memiliki SPO Identifikasi Pasien, Penyampaian Informasi, Rujukan, Informed Consent, Akses terhadap Rekam Medis, Penilaian kelengkapan dan ketepatan isi rekam medis, Kerahasiaan Rekam Medis. Oleh karena itu, perancang tertarik untuk merancang SPO Pelaksanaan Rekam Medis sesuai standar akreditasi klinik. Tujuan: Menyusun Standar Prosedur Operasional (SPO) Pelaksanaan Rekam Medis Sesuai Standar Akreditasi Klinik Di Klinik Korpagama UGM yang telah didukung oleh Surat Keputusan (SK) Kepala Klinik Metode: Perancangan dengan subyek seluruh petugas yang terkait dengan rekam medis meliputi : dokter umum, 1 perawat, 1 petugas rekam medis,1 petugas admin dan Obyek seluruh kegiatan rekam medis dan semua dokumen SPO. Pengambilan data dengan observasi, wawancara, Studi dokumentasi. Format SPO yang digunakan adalah Pedoman Penyusunan Dokumen Akreditasi FKTP(2017). Hasil: Klinik Pratama Korpagama UGM akan melaksanakan akreditasi yang pertama kali, sehingga semua komponen yang akan dinilai baik sarana dan prasana harus dipersiapkan dengan baik. Pendokumentasian SPO yang dimiliki oleh klinik belum lengkap dan optimal. Dengan menggunakan tahapan penyusunan SPO, Perancang merancang ulang 5 buah SPO dan menambahkan 7 buah SPO, maka tersusunlah keseluruhan 12 SPO yang telah di dukung oleh SK Kepala Klinik. Kesimpulan: Rancangan yang telah dibuat yaitu SPO pendaftaran Pasien BPJS, Pendaftaran Pasien Umum, Pengkodean, Penyimpanan dan Pengambilan, Penyusutan dan pemusnahan, Pelaporan, Identifikasi Pasien, Penyampaian Informasi, Rujukan, Informed Consent, Akses terhadap Rekam Medis, Penilaian kelengkapan dan ketepatan isi rekam medis , Kerahasiaan Rekam Medis . SPO tersebut didukung oleh SK Kepala Klinik.

Background: SPO is one aspect of the assessment of accreditation documents. The Primary Clinic of Korpagama UGM only has 5 SPOs. The five SPOs are not yet in accordance with FKTP's accreditation format (2017). Judging from the readiness of the SPO for the implementation of medical records, the Clinic does not yet have a Patient Identification SPO, Submission of Information, Referrals, Informed Consent, Access to Medical Records, Assessment of completeness and accuracy of medical record contents, Confidentiality of Medical Records. Therefore, the designer is interested in designing the SPO for Medical Record Implementation in accordance with clinical accreditation standards. Objective: To formulate Standard Operating Procedures (SPO) for Medical Record Implementation in Accordance with Clinical Accreditation Standards at the UGM Korpagama Clinic which has been supported by the Decree (SK) of the Head of Clinic. Methods: Design with the subjects of all officers related to medical records including: general practitioners, 1 nurse, 1 medical record officer, 1 admin officer and Object, all medical record activities and all SPO documents. Data retrieval by observation, interview, documentation study. The format of the SPO used is the Guidelines for Preparing the FKTP Accreditation Document(2017). Result: Primary Clinic of Korpagama UGM will carry out the first accreditation, so that all components that will be assessed both facilities and infrastructures must be well prepared. The SPO documentation owned by the clinic is incomplete and optimal. By using the preparation stages of the SPO, the Designer redesigned 5 SPOs and added 7 SPOs, then a total of 12 SPOs were compiled which were supported by the Decree of the Head of Clinic. Conclusion: The draft that has been made is SPO for BPJS Patient registration, General Patient Registration, Encoding, Storage and Retrieval, Depreciation and annihilation, Reporting, Patient Identification, Submission of Information, Referrals, Informed Consent, Access to Medical Records, Assessment of completeness and accuracy of record contents medical, confidentiality of medical records. The SPO is supported by the Decree of the Head of Clinic.

Kata Kunci : Akreditasi Klinik , Perancangan, Standar Prosedur Operasional