ANALISIS PENGISIAN CLINICAL PATHWAY SECTIO CESAREA DI RUMAH SAKIT PKU MUHAMMADIYAH YOGYAKARTA

NUR AINI RAMADANI, Rita Dian P., S.Kep.,M.PH

2017 | Tugas Akhir | D3 REKAM MEDIS SV

Latar Belakang: Pentingnya tindakan SC dalam persalinan yang tidak normal serta melihat tidak mudahnya dalam proses pembuatan CP, seharusnya dalam penerapannya dilakukan semaksimal mungkin. Akantetapi pengisian CP SC di RS PKU Muhammadiyah Yogyakarta belum maksimal hanya sebesar 87% ditahun 2016. Tujuan: Mengetahui proses pembuatan clinical pathway sectio cesarea, mengetahui pelaksanaan dan pengisian clinical pathway sectio cesarea, mengetahui kendala petugas dalam pengisian clinical pathway sectio cesarea, mengetahui upaya petugas dan manajemen dalam meningkatkan keterisian clinical pathway sectio cesarea. Metode: Jenis penelitian adalah penelitian deskriptif kualitatif dan menggunakan rancangan fenomenologis. Subjek penelitian ini adalah anggota komite medik, bidan dan perawat penanggungjawab clinical pathway. Objek penelitian ini adalah formulir clinical pathway pasien sectio cesarea, berkas rekam medis, SPO pembuatan clinical pathway. Hasil: Proses pengisian clinical pathway sectio cesarea dilakukan setelah berkas rekam medis pasien sampai ke bangsal dan diisi oleh perawat penanggungjawab shift. Proses pembuatan clinical pathway sudah diatur dalam SPO pembuatan clinical pathway. Kendala yang dialami petugas berdasarkan unsur manajemen 5M adalah unsur manajemen man tidak dilakuikan pengisian RM, Unsur manajemen materials formulir CP SC yang habis, unsur manajemen method tidak adanya SPO. Upaya petugas dalam meningkatkan keterisian dengan melakukan kontrol rekam medis sedangkan upaya yang dilakukan pihak manajemen dengan memberikan peringatan lisan dalam rapat serta kajian variasi yang muncul. Kesimpulan: Pengisian clinical pathway masih sangat rendah, perlu dilakukan evaluasi serta menetapkan SPO cara pengisian formulir clinical pathway.

Background: The importance of SC action in abnormal labor and difficulties in process of making CP should be done as much as possible However, CP SC filling in RS PKU Muhammadiyah Yogyakarta has not been maximal only 87% in 2016. Objective: To know the process of making clinical pathway sectio cesarea, to know the implementation and filling clinical pathway sectio cesarea, to know the obstacles officer in filling clinical pathway sectio cesarea, knowing the effort of officer and management in increasing clinical pathway sectio cesarea. Methods: The type of research is qualitative research and using phenomenological design. The subjects of this study were medical committee members, midwives and nurses in charge of clinical pathways. The object of this research is the clinical pathway form of patient sectio cesarea, medical record file, SOP making clinical pathway. Results: The process of filling clinical pathway sectio cesarea is done after the patient's medical record file gets to the ward and is filled by the shift responsible nurse. The process of making clinical pathway is arranged in SOP making clinical pathway. Obstacles experienced by officers based on the 5M management element are Man management element is not charged RM, Materials management elements is form CP SC out, Method management element is the absence of SOP. Attempts officers in improving the filling with medical record control while the efforts made by the management by providing verbal warnings in the meeting and study variation that appear. Conclusion: Filling clinical pathway is still very low, it is necessary to evaluate and establish SOP how to fill clinical pathway form.

Kata Kunci : Kata kunci: pengisian, clinical pathway, sectio cesarea/Keywords: filling, clinical pathway, sectio cesarea