Kinerja Peserta Program Pendidikan Dokter Spesialis (PPDS) I Dalam Pembuatan Resume Medis Di Departemen Obstetri Dan Ginekologi, RS. Dr. Cipto Mangunkusumo - Fakultas Kedokteran Universitas Indonesia, Jakarta

ANDON HESTIANTORO, Prof. dr. Hari Kusnanto, DrPH; Dr. dr. Andreasta Meliala, M.Kes., MAS

2017 | Tesis | S2 Ilmu Kesehatan Masyarakat

Latar belakang : Penulisan resume medis pasien Obstetri dan Ginekologi di Rumah sakit dr. Cipto Mangunkusumo dilakukan oleh peserta program pendidikan dokter spesialis (PPDS) I Obstetri dan Ginekologi. Di ruang rawat inap gedung A, selama periode januari – juni 2015, dijumpai kelengkapan resume medis di departemen Obstetri dan Ginekologi hanya berkisar antar 70-90% saja. Hal ini tentu berdampak tidak hanya kepada tatalaksana perawatan saja, namun juga berdampak terhadap keberhasilan klaim jaminan kesehatan BPJS. Penelitian ini bertujuan untuk mengetahui hubungan antara faktor-faktor seperti motivasi, ketrampilan dan perangkat resume medis, dengan kinerja PPDS menuliskan resume medis secara lengkap dan akurat. Metode : Penelitian ini menggunakan jenis penelitian kualitatif, dengan rancangan penelitian eksploratif, yang dilakukan di ruang rawat inap obstetri dan ginekologi, instalasi rawat inap gedung A lantai2, RSCM. Penelitian berlangsung sejak Agustus 2015 sampai dengan November 2015. Dilakukan diskusi terarah (focus group discussion) kepada PPDS dan wawancara mendalam (in depth interview) kepada dokter konsulen, dilanjutkan dengan observasi langsung terhadap kegiatan dilapangan dan resume medis pasien. Hasil : Telah dilakukan diskusi terarah dengan 35 PPDS OBGIN dan wawancara mendalam dengan 10 dokter konsulen. Dilakukan observasi kelengkapan 100 resume medis konvensional, dan dilakukan kajian akurasi diagnosis utama terhadap 6 resume medis elektronik. Sebagian besar PPDS memiliki persepsi bahwa penulisan resume medis yang lengkap dan akurat merupakan hal penting untuk tatakelola pasien dan untuk klaim jaminan kesehatan BPJS. PPDS telah memperoleh pelatihan terkait cara penulisan resume medis yang benar, namun tetap memerlukan pendampingan dari konsulen. Perangkat keras resume medis sudah baik, namun resume medis elektronik dapat membantu kelengkapan resume medis mencapai 100%. Kegiatan supervisi dari dokter konsulen hanya sekitar 50% saja. Supervisi dokter konsulen diperlukan untuk meningkatkan keterampilan PPDS dan sekaligus menjaga akurasi resume medis. Kesimpulan: Kurangnya supervisi dokter konsulen berdampak kepada kurangnya keterampilan PPDS menuliskan resume medis yang lengkap dan akurat. Resume medis elektronik dapat digunakan untuk menjaga kelengkapan penulisan resume medis, namun untuk akurasi data resume medis diperlukan supervisi dokter konsulen yang baik.

Bacground : Discharge summaries of Obstetrics and Gynecology of inpatients at the building A dr. Cipto Mangunkusumo hospital are prepared and fulfiled by Obstetrics and Gynecology resident as part of their training program, during the period January - June 2015. We encountered completeness of discharge summaries in the department of obstetrics and gynecology only ranges between 70-90%. This would impact not only to the management of maintenance, but also have an impact on the success of health insurance claims namely BPJS. This study aims to determine the relationship between factors such as motivation, skills and discharge summaries devices, with the performance of OBGYN resident by means of adequacy of written discharge summaries. Method : This study is qualitative study with explorative approach, which was taken place at inpatient ward of building A, RSCM. This study was conducted since August 2015 until November 2015. We organized focus group discusiion for residents and indepth interview with consultant doctors for collecting information and data. In addition, we did close observation for all related filed activites associated with discharge summaries management. Results : We organized focus group discusion with variant levels of 35 OBGYN residents, and did indepth interview with variant experince of 10 consultant doctors. Most of them showed a good perception about how important the adquacy of discharge summaries should be managed, in supporting patients management and handling coverage for national medical insurance (BPJS). All respondent from OBGYN residents had already been trained for managing discharge summaries adequately, eventhough mentoring from consultant is needed. We observed that hard copy of conventional form of discharge summaries at our department is already good, however 100% completenes was achieved used electronic discharge summaries. The consultant supervision activities occured only as much as 50%. Consultant doctor's supervision is needed to improve the skills of PPDS and simultaneously maintaining adequacy discharge summaries. Conclusion: Lack of supervision from consultant would impact the lack of PPDS skills in fulfilling discharge summaries complete and accurate. Electronic discharge summaries can be used to maintain the completeness of the discharge summaries, however, to keep the accuracy of discharge summaries, it is needed the intervention dan supervision of good consultant

Kata Kunci : Discharge summaries, completeness, accuracy, supervision