LITERATURE REVIEW : KETIDAKLENGKAPAN PENGISIAN RESUME MEDIS PASIEN RAWAT INAP DI RUMAH SAKIT

NUR HUWAIDAH R, Angga Eko Pramono, S.K.M., M.P.H.

2022 | Tugas Akhir | D4 MANAJEMEN INFORMASI KESEHATAN

Latar Belakang : Resume medis memiliki peran penting dalam dalam upaya pelayanan kesehatan. Ketidaklengkapan pengisian resume medis dapat mengakibatkan berbagai dampak pada rumah sakit. Banyak penelitian yang telah dilakukan mengenai kelengkapan pengisian resume medis. Hasil penelitian tersebut menunjukkan bahwa kualitas pendokumentasian resume medis masih kurang baik. Oleh karena itu dilakukan penelitian ini untuk mengetahui kelengkapan pengisian rekam medis beserta faktor penyebab ketidaklengkapannya untuk menentukan strategi peningkatakan kualitas pendokumentasian resume medis. Tujuan : Mengevaluasi kelengkapan pengisian resume medis pasien rawat inap di rumah sakit. Metode : Penelitian berjenis Systematic Literature Review. Pencarian literatur menggunakan metode PRISMA flow diagram. Sumber data diperoleh dari Google Scholar dan jurnal publikasi lainnya. Hasil : Hasil seleksi studi dan penelitian kualitas menunjukkan 7 literatur layak untuk di-review. Berdasarkan hasil tersebut masih banyak ketidaklengkapan pengisian resume medis. Terdapat 7 faktor penyebab ketidaklengkapan yang disusun berdasarkan unsur manajemen 5M. Review terhadap upaya mengatasi ketidaklengkapan memperoleh 6 alternatif solusi. Kegiatan scoring menghasilkan 3 alternatif solusi yang paling banyak disarankan oleh literatur yang di-review. Kesimpulan : Kelengkapan pengisian resume medis belum sesuai dengan Kepmenkes Nomor 129/MENKES/SK/II/2008. Faktor penyebab ketidaklengkapan terdapat pada unsur manajemen man, material, dan methods. Pembuatan dan sosialisasi SPO, pengarahan kepada dokter serta pemantauan oleh komite khusus terkait pengisian resume medis, dan pembuatan kebijakan terkait reward dan punishment merupakan 3 alternatif solusi yang terpilih berdasarkan kegiatan scoring.

Background : Medical resume has an important role in health services. Incomplete filling of medical resumes can have various impacts for hospital, it can be affect the evaluation of service quality. Many studies have been conducted regarding the completeness of medical resume. This shows that the quality of medical resume documentation is still not good. Therefore, this study was conducted to determine the completeness of medical records and the factors that cause incompleteness based on selected literature to determine strategies to improve the quality of medical resume documentation. Objective : To review the literature related to the completeness filling of medical resume in hospital. Method : The research type is Systematic Literature Review using PRISMA flow diagram method with data sources from Google Scholar and other published journals. Results : The results showed that 7 literatures deserve to be review. Based on these review, there are still many incomplete medical resumes, there are 7 factors that cause incompleteness. Review of solutions to overcome incompleteness obtains 6 alternative solutions. The scoring activity resulted 3 alternative solutions that were most recommended by the reviewed literature. Conslusion : Based on these review, the completeness of the medical resume is not appropriate with Kepmenkes 129/MENKES/SK/II/2008. The factors that cause incompleteness are elements of man, material, and methods. Making and socializing SOPs, directing to doctors and monitoring by a special committee regarding the completeness of medical resumes, and making policies related to reward and punishment are 3 alternative solutions that were chosen based on scoring activities.

Kata Kunci : Kata Kunci : analisis kuantitatif, rekam medis, resume medis