TELAAH REKAM MEDIS TERTUTUP TERKAIT CONSENT PASIEN SECTIO CAESAREA DI RSUD BAGAS WARAS KLATEN

PREDITA INTI D, Savitri Citra Budi, S.KM., M.P.H.

2017 | Tugas Akhir | D3 REKAM MEDIS SV

Latar Belakang : Telaah rekam medis tertutup merupakan salah satu aspek yang akan disurvei dalam KARS 2012. RSUD Bagas Waras Klaten akan melaksanakan akreditasi sesuai KARS 2012, namun belum pernah telaah rekam medis tertutup. Oleh karena itu diperlukan penelitian untuk mengetahui hasil telaah rekam medis tertutup terkait consent pasien sectio caesarea sesuai KARS 2012. Tujuan : Mengetahui pelaksanaan pengisian, isi formulir, persentase kelengkapan, faktor penyebab, dan upaya untuk mengatasi ketidaklengkapan. Metode : Jenis penelitian ini menggunakan penelitian deskriptif dengan pendekatan kualitatif. Teknik pengumpulan data dengan wawancara, observasi, dan studi dokumentasi. Uji keabsahan data dengan triangulasi sumber dan teknik. Pengambilan sampel objek menggunakan random sampling. Hasil : Persetujuan dan pemberian informasi sebelum tindakan medis sudah dilaksanakan. General consent berisi informasi pemeriksaan dasar yang dilakukan. Sedangkan informed consent berisi pernyataan persetujuan dan informasi tindakan medis. Persentase kelengkapan untuk standar HPK.6.3 sebesar 18,18%, 0% pada HPK.6.4, 62,12% pada PAB.5.1 dan 63,64% pada PAB.7.1. Faktor yang menyebabkan ketidaklengkapan adalah kesibukan, ketidaktelitian, dan kelalaian individu, SPO belum ditetapkan, belum sosialisasi, belum analisis kuantitatif pada informed consent, dan item formulir belum sesuai kebutuhan. Upaya yang dilakukan untuk mengatasi ketidaklengkapan adalah komunikasi, evaluasi pengisian, pengecekan kelengkapan, dan revisi formulir. Kesimpulan : Pelaksanaan consent sesuai standar KARS 2012, isi general consent belum sesuai standar KARS 2012, sedangkan isi informed consent sesuai standar KARS 2012, persentase kelengkapan tertinggi pada standar PAB.7.1, faktor penyebab dan upaya mengatasi ketidaklengkapan dapat dilihat dari aspek manusia, metode, dan material. Kata Kunci : Telaah rekam medis tertutup, Consent pasien sectio caesarea, KARS 2012

Background : Close medical record review is one of the aspect that is survey in KARS 2012. Bagas Waras Klaten Public Hospital will be implement appropriate KARS 2012 accreditation, but never did examine closed medical record. Therefore, research is needed to find out the results of closed medical record review sectio caesarea patient appropriate KARS 2012. Objective : This research aimed to know the implementation filling, the formulir contents, the percentage of completeness, the factors that cause incomplete filling, and effort to overcome the completeness. Methods : This type of research used descriptive study with qualitative approach. Data collection techniques used by interview, observation, and documentation. Data validation used by triangulation sources and techniques. Sampling object using random sampling. Results : Approval and delivery of medical information before actions has been implemented. General consent contain basic checks information. While informed consent contains a statement of consent and medical treatment information. The percentage of completeness for HPK.6.3 standard is 18.18%, 0% on HPK.6.4, 62.12% on PAB.5.1 and 63.64% on PAB.7.1. Factors that cause incompleteness is busyness, inaccuracy and omissions of individuals, SOP has not been established, yet socialization, yet quantitative analysis on informed consent, and the item is not as necessary form. Efforts are being made to overcome the incompleteness is communication, evaluation filling, checking the completeness, and the revision of the form. Conclusion : Implementation of consent appropriate KARS 2012 standard, the contents of general consent has not been standardized KARS 2012, while the content of informed consent appropriate KARS 2012 standard, the highest of completeness percentage in PAB.7.1 standards, causes and efforts to overcome the incompleteness can be seen from the human aspect, methods, and materials. Keywords : Closed medical record review, consent of sectio caesarea patient, KARS 2012.

Kata Kunci : Telaah rekam medis tertutup, Consent pasien sectio caesarea, KARS 2012