TINJAUAN PERSIAPAN AKREDITASI TERKAIT STANDAR MANAJEMEN INFORMASI REKAM MEDIS DI PUSKESMAS MERTOYUDAN II KABUPATEN MAGELANG

UMI LARA KURNIA, Susilawati, S.K.M., M.P.H.

2017 | Tugas Akhir | D3 REKAM MEDIS SV

Latar Belakang: Manajemen Informasi Rekam Medis merupakan salah satu standar yang dinilai pada akreditasi puskesmas seperti yang terlampir pada Permenkes 46 tahun 2015. Puskesmas Mertoyudan II merupakan puskesmas yang belum pernah melaksanakan akreditasi. Oleh karena itu, persiapan akreditasi sangat diperlukan. Tujuan: Mengetahui persiapan akreditasi pada standar 8.4 manajemen informasi rekam medis. Metode: Jenis penelitian: penelitian deskriptif dengan pendekatan kualitatif dan rancangan penelitian studi kasus. Subjek penelitian: perekam medis, dua orang pembantu perekam medis, kepala puskesmas. Objek penelitian: standar operasional prosedur, surat keputusan, dokumen terkait manajemen informasi rekam medis. Teknik pengumpulan data: studi dokumentasi, wawancara, observasi. Keabsahan data menggunakan triangulasi sumber. Hasil: Persiapan akreditasi yang sudah dilakukan: tersedia standarisasi kode klasifikasi diagnosis dan terminologi lain yang konsisten dan sistematis, tersedia standarisasi kode klasifikasi yang dibuat oleh puskesmas, tersedia pembakuan singkatan yang digunakan dalam pelayanan. Tersedia SK dan SOP Akses terhadap Rekam Medis, akses petugas terhadap informasi medis sesuai dengan tugas dan tanggung jawab serta dilaksanakan sesuai kebijakan dan prosedur. Tersedia SK Pelayanan Rekam Medis dan Metode Indentifikasi, SK Pengkodean, Penyimpanan, dan Dokumentasi Rekam Medis, SOP Penomoran Rekam Medis dan Family Folder, SOP Penyimpanan Family Folder, tersedia rekam medis bagi setiap pasien. Isi rekam medis mencakup diagnosis, pengobatan, hasil pengobatan dan kontinuitas asuhan, tersedia SOP Penilaian Kelengkapan dan Ketetapan Isi Rekam Medis. Hal yang belum dilakukan: penyediaan daftar simbol singkatan yang tidak boleh digunakan, SOP Identifikasi Pasien, pendokumentasian rekam medis, kejelasan masa retensi, SOP retensi berkas rekam medis, SOP Menjaga Kerahasiaan Rekam Medis, penilaian dan tindak lanjut kelengkapan ketepatan isi rekam medis. Kesimpulan: Masih terdapat beberapa dokumen dan kegiatan akreditasi yang belum dipersiapkan di Puskesmas Mertoyudan II.

Background: Medical Record Information Management is one of accreditation standards which is assessed in Puskesmas (Local Government Clinic) accreditation enclosed to Permenkes (Public Health Ministerial Regulation) 45 in 2015. Puskesmas Mertoyudan II is a Local Government Clinic which has not ever done accreditation process. Therefore, accreditation preparation is needed. Objective: The objective of this study is to determine the accreditation preparation in 8.4 standard of medical record information management. Methods: The type of this research is descriptive research with qualitative approach and case study design. The subjects of this study are an officer of medical record, two assistants of medical record officer and the head of puskesmas. The object of this study are standard operating procedures (SOP), decree (SK), and several documents related to medical record information management. Data collection techniques used in this study were documentation study technique, interview and observation. The data validity used were triangulation. Result: Accreditation Preparation which has been done are: code standardization of diagnosis classification and another terminology which are consistent and systematic, code standardization of classification and another terminology which are made by the puskesmas, standardization of acronyms used in the service. There are also access decree towards medical record, access SOP towards medical record, access of the officers towards medical information needed appropriate to duty and responsibility, access of the officers towards medical information which is appropriate to the policy and procedure, right to access medical information with the consideration of the level of information secrecy and security. Decree of medical record service and identification method, medical record for every patient, decree of coding, saving and medical record documentation, SOP of medical record numbering and family folder, and SOP of family folder saving are all available. The content of medical record includes diagnosis, therapy, therapy result and given upbringing continuity, and also SOP of completeness assessment and the determination of medical record content. Things that have not been done are: providing list of symbol and forbidden acronyms, SOP of patients identification, medical record documentation, establishing retention period, providing SOP of medical record file retention, assessment and next step for completeness and determination of medical record content and providing SOP of keeping medical record secrecy. Conclusion: There are still several documents and accreditation activities which are not prepared yet by Puskesmas Mertoyudan II.

Kata Kunci : persiapan akreditasi, akreditasi puskesmas, manajemen informasi rekam medis