FAKTOR PENYEBAB DAN DAMPAK KETIDAKLENGKAPAN PENGISIAN LEMBAR INFORMED CONSENT PASIEN BEDAH MULUT DI RSUP dr. SOERADJI TIRTONEGORO KLATEN

WAHYU TRI HERDIANA, Savitri Citra Budi, SKM, MPH

2016 | Tugas Akhir | D3 REKAM MEDIS SV

Latar Belakang : Lembar informed consent dapat dijadikan bukti dan memiliki nilai hukum yang kuat. Informed consent berupa selembar kertas yang berisi penjelasan dokter tentang diagnosa, tindakan, alternatif tindakan, prognosis atau akibat yang terjadi dari tindakan yang dilakukan, selain itu berisi pernyataan bahwa pasien telah mengerti tentang informasi yang disampaikan dokter dan menyetujui dengan tanda tangan pasien/keluarga pasien serta tanda tangan dokter. Informed consent wajib diinformasikan kepada pasien oleh dokter berkaitan tindakan medik yang dilakukan. Lembar informed consent harus diisi secara lengkap. Namun masih ditemukan ketidaklengkapan pengisian pada lembar informed consent di beberapa item. Ketidaklengkapan pengisian lembar rekam medis dapat berdampak pada mulu pelayanan rekam medis. Tujuan : Mengetahui faktor penyebab ketidaklengkapan pengisian lembar informed consent pasien bedah mulut, mengetahui upaya yang dilakukan oleh petugas rekam medis dan mengetahui dampak ketidaklengkapan lembar informed consent pasien bedah mulut. Metode : Deskriptif kualitataif dengan rancangan fenomenologi. Objek penelitian lembar informed consent pasien bedah mulut tahun 2015. Subjek penelitian tenaga medis, perekam medis dan kepala rekam medis Hasil : Faktor ketidaklengkapan lembar informed consent yaitu Sumber Daya Manusia (SDM) meliputi jumlah ketersediaan dokter spesialis bedah mulut dan kesibukan dokter. Kemudian kurangnya komunikasi antara dokter dengan perawat dan belum adanya reward and punishment. Upaya yang dilakukan oleh petugas rekam medis terhadap ketidaklengkapan lembar informed consent pasien bedah mulut yaitu mengembalikan lembar informed consent ke ruang perawatan dan melakukan rapat triwulan untuk evaluasi kelengkapan lembar informed consent. Dampak ketidaklengkapan yaitu mengurangi mutu rekam medis dan lemah hukum. Kesimpulan: 1. Faktor penyebab ketidaklengkapan pengisian lembar informed consent pasien bedah mulut di RSUP dr. Soeradji Tirtonegoro Klaten meliputi faktor SDM (Sumber Daya Manusia) dan sarana dan prasarana. 2. Dampak ketidaklengkapan pengisian lembar informed consent pasien bedah mulut di RSUP dr. Soeradji Tirtonegoro Klaten yaitu mengurangi nilai indikator mutu rekam medis dan lembar informed consent lemah hukum. 3. Upaya yang dilakukan oleh petugas rekam medis terhadap ketidaklengkapan pengisian lembar informed consent pasien bedah mulut di RSUP dr. Soeradji Tirtonegoro Klaten yaitu mengembalikan lembar informed consent ke bangsal perawatan dan melakukan rapat triwulan untuk mengevaluasi kelengkapan lembar informed consent.

Background: The sheet of informed consent can be used as evidence and have the value of a strong law. Informed consent in the form of a sheet of paper that contains the explanation of the doctor about diagnosis, action, alternative measures, prognosis or consequence that occurs from the actions taken, moreover contains a statement that the patient understands the information conveyed about the doctor and agree with the signature of the patient/patient's family as well as the doctor's signature. Mandatory informed consent to patients by physicians pertaining to medical action undertaken. Informed consent sheet must be filled in completely. Incomplete filling of medical record sheet can have an impact on the quality of medical record completeness. Objective: to know the factors cause incomplete charging sheet of informed consent of patients oral surgery, knowing the efforts made by the officers of the medical record and know the impact of incomplete sheet of informed consent of patients oral surgery. Methods: Descriptive kualitataif phenomenology design. Object of research informed consent sheet oral surgery patients by 2015. Subject research medical personnel, medical recorder and Chief of medical record. Results: Factor incomplete sheet of informed consent that is the human resources (HR) includes the amount of availability of specialist oral surgery and the bustle of the doctor. Then the lack of communication between doctors and nurses have not been with the existence of reward and punishment. The efforts made by officers against medical record incomplete sheet of informed consent of patients oral surgery i.e. returns sheet informed consent to treatment rooms and perform quarterly meetings for the evaluation of the completeness of the informed consent sheet. The impact of incompleteness that is reducing the quality of the medical record and the weak law. Conclusions: 1. Factors cause incomplete charging sheet of informed consent of patients in oral surgery was Dr. Soeradji Tirtonegoro Klaten include HUMAN RESOURCE factor (human resources) and facilities and infrastructure. 2. The impact of incomplete filling sheets of informed consent of patients in oral surgery was Dr. Soeradji Tirtonegoro Klaten i.e. reduce the value indicators of the quality of medical record and weak law of informed consent sheet. 3. Efforts made by officers against medical record incomplete charging sheet of informed consent of patients in oral surgery was Dr. Soeradji Tirtonegoro Klaten informed consent sheet i.e. returns to the wards and conduct quarterly meetings to evaluate the completeness of the informed consent sheet.

Kata Kunci : Informed consent, bedah mulut, pengisian, ketidaklengkapan, mouth surgical, filling up, incompleteness