PERANCANGAN ULANG FORMULIR DAN STANDAR OPERASIONAL PROSEDUR (SOP) PENGISIAN REKAM MEDIS RAWAT JALAN SEBAGAI BAHAN PRAKTIK DI LABORATORIUM REKAM MEDIS SEKOLAH VOKASI UNIVERSITAS GADJAH MADA

PAVITRA NOVERINDA A, Dian Budi Santoso, S.K.M., M.P.H.

2021 | Tugas Akhir | D3 REKAM MEDIS DAN INFORMASI KESEHATAN

Latar Belakang: Formulir rekam medis sangat dibutuhkan sebagai bahan praktik mahasiswa Program Studi Rekam Medis di Sekolah Vokasi Universitas Gadjah Mada. Saat ini, masih menggunakan formulir lama sehingga perlu perancangan ulang formulir sesuai perkembangan sekarang. Selain itu, belum terdapat SOP pengisian formulir. Tujuan: Merancang ulang formulir dan SOP pengisian rekam medis rawat jalan sebagai bahan praktik Laboratorium Rekam Medis di Sekolah Vokasi Universitas Gadjah Mada. Metode: Metode perancangan formulir pasien rawat jalan dan SOP Pengisian formulir menggunakan metode dan langkah pengembangan formulir menurut RCH Forms Committee 2006. Subjek penelitian ini adalah satu orang dosen, staff laborator dan triangulasinya adalah praktisi yang mengajar Desain Formulir. Peneliti melakukan studi dokumentasi dan wawancara. Terdapat dua alternatif rancangan formulir rekam medis rawat jalan. Pemilihan desain, bahan dan perbaikan formulir dilakukan melalui diskusi bersama informan. Uji coba formulir dilakukan kepada informan triangulasi. Hasil: Hasil analisis aspek fisik formulir terpilih menggunakan kertas HVS 80 gram dengan ukuran kertas A4 (21 cm x 29,7 cm), margins atas 1 cm bawah 1,27 cm kiri 2 cm kanan 1 cm. Format formulir berdasarkan aspek desain formulir dan isinya mengacu pada Permenkes 269 Tahun 2008. Hasil akhir rancangan formulir yang terdiri atas KIB, KIUP, ringkasan riwayat klinik, lembar poliklinik, dan hasil penempelan laboratorium serta SOP pengisian formulir secara umum, dan petunjuk pengisian pada masing-masing formulir. Kesimpulan : Hasil perancangan formulir pasien rawat jalan dan SOP pengisian formulir telah memenuhi kebutuhan Laboratorium, aspek desain formulir dan standar akreditasi. Kata Kunci: Perancangan ulang, formulir rawat jalan, SOP.

Background: Medical record forms are needed as practice material for students of the Medical Record at the Vocational School of Gadjah Mada University. Currently, the old form are still used, so redesign the form according to current developments is needed. In addition, there is no SOP for filling out forms. Objective: To redesign the form and filling outpatient medical records SOP as practice material for the Medical Record Laboratory at the Vocational School of Gadjah Mada University. Method: The method was refer to the 2006 RCH Forms Committee. The subjects were a lecturer, a laboratory staff, and a practitioner who teaches Form Design as triangulation. Researchers conducted a study of documentation and interviews. There were two alternative designs for outpatient medical record forms. The selection of designs, materials, and form improvements was carried out through discussion group. The trials were carried out to triangulated informants. Results: The results of the physical aspects analysis were 80 gsm A4 HVS paper, top margins 1 cm, below 1.27 cm, left 2 cm, right 1 cm. The form format is based on aspects of form design and its contents refer to Permenkes 269 of 2008. The final results consist of KIB, KIUP, summary of clinical history, polyclinic sheets, and laboratory attachment results as well as SOP for filling out forms in general, and instructions for filling. Conclusion: The results of the outpatient form design and SOP form filling had fulfilled the laboratory needs, form design aspects, and accreditation standards. Keywords: Redesign, outpatient form, SOP.

Kata Kunci : Perancangan ulang, formulir rawat jalan, SOP