TINJAUAN PROSES TRANSISI REKAM MEDIS MANUAL MENUJU ELEKTRONIK PADA PELAYANAN UNIT REKAM MEDIS DI RUMAH SAKIT ISLAM KLATEN

FAJAR ROFIK NUR K, Dr. Nur Rokhman, S.Si., M. Kom.

2019 | Tugas Akhir | D3 REKAM MEDIS DAN INFORMASI KESEHATAN

Latar Belakang: RSI Klaten merupakan rumah sakit yang telah menerapkan rekam medis elektronik pada pelayanan rawat jalan dan IGD yang akhirnya akan menerapkan RME secara total. Proses transisi rekam medis manual ke elektronik membutuhkan langkah-langkah yang tepat agar terarah dan dapat dipertanggungjawabkan. Oleh karena itu, diperlukan penelitian mengenai proses transisi Tujuan: Mengetahui proses transisi rekam medis manual ke elektronik pada pelayanan unit rekam medis di RSI Klaten Metode: Jenis penelitian adalah penelitian deskriptif kualitatif dengan pendekatan fenomenologi. Subjek penelitian adalah tujuh orang yang terdiri dari petugas pendaftaran, perawat, petugas pelaporan, petugas farmasi, petugas radiologi, petugas laboratorium dan kepala rekam medis. Teknik pengambilan data dengan teknik observasi, wawancara dan studi dokumentasi. Uji keabsahan data dengan triangulasi. Hasil: Proses transisi di RSI diawali didukung penuh oleh pimpinan sehingga akhirnya RSI melakukan sosialisasi pelaksanaan RME, melakukan studi banding, menetapkan perubahan yang dinginkan yaitu rekam medis yang akan dikomputerisasi, melakukan ujicoba, melakukan pendampingan dan sosialisasi pengisian RME, RSI mulai mengimplementasikan RME, mengadakan penilaian kinerja secara global dan melakukan evaluasi secara berkala. Kesimpulan: Proses transisi rekam medis manual ke elektronik sudah sesuai dengan teori Anderson and Anderson Nine Phase Change Process Model walaupun RSI tidak menganut teori atau model manajemen apapun karena proses transisi dibuat oleh RSI dibawah pengawasan panitia tim RME dan EDP.

Background: RSI Klaten is a hospital that has implemented electronic medical records in outpatient services and emergency departments that will eventually apply the total RME. The process of manual medical record transition to electronics requires the right steps to be directed and accountable. Therefore, research is needed on the transition process. Objective: To find out the process of manual medical record transition to electronics in the medical record unit service at RSI Klaten. Method: This type of research is a qualitative descriptive study with a phenomenological approach. The research subjects were seven people consisting of registration officers, nurses, reporting officers, pharmacists, radiology officers, laboratory officers and medical record heads. Data collection techniques with observation, interview and documentation study techniques. Test the validity of data by triangulation. Results: The transition process at the RSI was started fully supported by the leadership so that the RSI finally disseminated the implementation of the RME, conducted comparative studies, determined the changes is medical record that would be computerized, conducted trials, provided assistance and socialized the filling of RME, RSI began implementing RME, held an assessment global performance and periodic evaluations. Conclusion: The process of manual medical record transition to electronics is in accordance with Anderson and Anderson's Nine Phase Change Process Model theory even though the RSI does not adhere to any management theory or model because the transition process was made by RSI under the supervision of the RME and EDP team committee.

Kata Kunci : rekam medis elektronik, rekam medis manual, proses transisi.