ANALISIS ISI REKAM MEDIS RAWAT INAP BERDASARKAN STANDAR AKREDITASI PUSKESMAS DI PUSKESMAS BALONG PONOROGO

TITIN TRI RAHAYU, Savitri Citra Budi, S.K.M., M.P.H

2017 | Tugas Akhir | D3 REKAM MEDIS SV

Latar Belakang: Puskesmas wajib diakreditasi secara berkala paling sedikit 3 tahun sekali. Berdasarkan Studi Pendahuluan dengan Kepala Puskesmas pada bulan Januari 2017 bahwa Puskesmas Balong sedang mempersiapkan akreditasi puskesmas di tahun 2017. Tujuan: Mengetahui hasil kesesuaian isi berkas rawat inap, faktor penyebab ketidaklengkapan berkas rawat inap dan upaya mengatasi ketidaklengkapan berkas rawat inap terkait Standar Akreditasi Puskesmas. Metode: Penelitian deskriptif dengan pendekatan kualitatif dan rancangan penelitian studi kasus. Subjek 4 perawat, 4 dokter, 1 petugas pendaftaran. Objek 59 berkas non tindakan dan 15 berkas tindakan. Teknik pengambilan data studi dokumen, observasi dan wawancara. Uji keabsahan data menggunakan triangulasi sumber dan teknik. Hasil: Hasil analisis kesesuaian item data di rekam medis rawat inap berdasarkan Standar Akreditasi Puskesmas di Puskesmas Balong Ponorogo meliputi, identitas pasien, anamnesa, pemeriksaan fisik, rencana layanan, pemeriksaan penunjang, efek samping obat, diagnosa, pengobatan dan kontinuitas layanan. Hasil analisis persentase item berkas rekam medis rawat inap berdasarkan Standar Akreditasi Puskesmas meliputi, LKBP (7.6.1 EP 5 sebesar 83,33% dan 7.6.1 EP 7 sebesar 79,66%), MPLK 8.4.4 EP 1 sebesar 74,99%, LKBP (7.2.2 EP 1 sebesar 74,15%, 7.4.3 EP 6 sebesar 57,62%, 7.4.4 EP 4 sebesar 6,66% dan 7.7.2 EP 7 sebesar 0%), MPLK 8.2.4 EP 2 sebesar 0% serta LKBP (7.7.1 EP 5 dan 7.7.2 EP 6 tidak dapat dinilai). Faktor penyebab meliputi, Man yaitu pasien banyak, petugas kurang memahami SOAP, petugas kurang tahu riwayat penyakit pasien, lupa, waktu bertepatan dengan rapat, kurang memahami SOP, dan waktu kerja terbatas, Method yaitu sosialisasi SOP masih kurang, kurangnya sosialisasi pengisian SOAP dan SOP kurang jelas. Upaya yang dilakukan meliputi, membuat laporan, pembinaan, pemberian saran-saran, operan shift, sosialisasi pengisian rekam medis, sosialisasi SOP, dilakukan pendekatan, evaluasi dan monitoring.

Background: Accredited Puskesmas regulary required at least every 3 years. Based on Preliminary Study by the Head of Puskesmas in January 2017 that the Puskesmas is preparing accreditation 2017. Objectives: : Study result was suitability content in medical record inpatient, factor causing incompleteness medical record inpatient and effort for incopleteness medical record inpatient based on Puskesmas Accreditation Standard. Methods: The study was descriptive qualitative approach and case study design. Subject 4 nurses, 4 doctor, 1 registration employee. Object 59 medical record non procedure and 15 medical record procedure. Data collected with research documentation, observation, and interview. Legitimate tes with source and technique triangulasi. Results: The results of analysis the suitability of the data item on inpatient medical records base on Puskesmas Accreditation Standards in Puskesmas Balong Ponorogo include the identity of the patient, anamnesis, physical examination, plan services, investigations, side effects of drugs, diagnostics, treatment and service continuitas. The results of analysis the contents of occupancy inpatient medical record file based Puskesmas Accreditation Standards include, LKBP (7.6.1 EP 5 is 83,33% and 7.6.1 EP 7 is 79,66%), MPLK 8.4.4 EP 1 is 74,99%, LKBP (7.2.2 EP 1 is 74,15%, 7.4.3 EP 6 is 57,62%, 7.4.4 EP 4 is 6,66% and 7.7.2 EP 7 is 0%), MPLK 8.2.4 EP 2 is 0% and LKBP (7.7.1 EP 5 and 7.7.2 EP 6 can not valued). Factors causing incompleteness include, Man is a patient lot, the attendant lack of understanding of SOAP, officers do not know the medical history of the patient, forget, time to coincide with the meeting, do not understand the SOP, and the working time is limited, Method are socializing SOP is still lacking, lack of socialization charging SOAP and SOP is less clear. Efforts that have been made include, make reports, coaching, giving suggestions, operand shift, medical records filling socialization, socialization SOP, do approach, evaluation and monitoring.

Kata Kunci : Akreditasi Puskesmas, analisis, faktor ketidaklengkapan rekam medis, upaya/Accreditation Puskesmas, analysis, medical records incompleteness factor, effort