ANALISIS KELENGKAPAN PENGISIAN FORMULIR CATATAN PERKEMBANGAN TERINTEGRASI PASIEN RAWAT INAP BERDASARKAN SOAP DI RST Dr. SOEDJONO MAGELANG

NUR APRIANI FIRADATY, Savitri Citra Budi, SKM., MPH.

2017 | Tugas Akhir | D3 REKAM MEDIS

ABSTRAK LatarBelakang: Metode penulisan catatan perkembangan berisi informasi tambahan yang diperoleh selama pengelolaan masalah yaitu berupa data subjektif, data objektif, data analisis dan rencana baru yang biasa di singkat SOAP (Subjective, Objective, Analysis, Plan). Kesesuaian pengisian SOAP sangat penting karena mengandung berbagai informasi dan juga digunakan sebagai alat pembenaran, pengambilan keputusan, dan tindak lanjut perawatan pasien. Berdasarkan studi pendahuluan yang dilakukan peneliti dengan studi dokumentasi dan wawancara dengan kepala instalasi rekam medis di RST Dr. Soedjono Magelang diketahui bahwa masih terdapat ketidakonsistenan dalam pencatatan padaformulir catatan perkembangan terintegrasi pasien rawat inap berdasarkan SOAP Tujuan: Menganalisis kelengkapan dan ketidaklengkapan pengisian formulir catatatan perkembangan terintegrasi pasien rawat inap berdasarkan SOAP dan Mengetahui faktor-faktor penyebab ketidaklengkapan pengisian formulir catatan perkembangan terintegrasi pasien rawat inap berdasarkan SOAP di RST Dr. Soedjono Magelang. Metode:Jenis penelitian ini adalah penelitian deskriptif dengan menggunakan pendekatan kualitatif. Rancangan penelitian yang digunakan adalah studi kasus. Subjek dalam penelitian ini adalah petugas rekam medis,perawat bangsal dan kepala instalasi rekam medis. Objek dalam penelitian ini adalah 100 berkas rekam medis pasien rawat inap. Teknik pengumpulan data dengan observasi, wawancara dan studi dokumentasi. Untuk validasi data menggunakan triangulasi sumber. Penelitian ini dilakukan di ruang instalasi rekam medis dan instalasi rawat inap. Hasil: Berdasarkan hasil analisis dari 100 berkas rekam medis pasien rawat inap yang didalamnya terdapat formulir catatan perkembangan terintegrasi pasien rawat inap diperoleh hasil persentase kelengkapan pencatatan berdasarkan SOAP sebesar 54% dan pencatatan tidak lengkap berdasarkan SOAP sebanyak 46%. Faktor penyebab ketidaklengkapan pengisian adalah Sumber daya manusia dalam hal ini dokter dan perawat harus memiliki pengetahuan, kompetensi yang mencakup loyalitas, kedisiplinan, kejasama dan tanggung jawab agar meningkatkan dalam kinerja terhadap pelayanan kepada pasien dan pengisian berkas rekam medis yang lengkap, belumterdapatdaftarsingkatan yang disepakatidanseringdigunakanolehparapetugasmedis yang mengisikanformulircatatanperkembanganterintegrasisertabelumadainstruksimengenaipengisianpadaformulircatatanperkembanganterintegrasirawatinap.dan belum terdapat standar operasional prosedur (SOP) tentang pencatatan SOAP pada formulir catatan perkembangan terintegras pasien rawat inap.

ABSTRACT Background: The method of writing development notes contains additional information gained during problem management that is in the form of subjective data, objective data, analytical data and the usual new plan in short SOAP (Subjective, Objective, Analysis, Plan). The compliance of SOAP filling is very important because it contains various information and also used as a means of justification, decision-making, and follow-up patient care. Based on a preliminary study conducted by researchers with documentary studies and interviews with the head of medical record installation at Dr. RST.SoedjonoMagelang note that there is still inconsistency in recording on the integrated development records form of inpatients based on SOAP Objectives: Analyze the completeness and incomplete filling out forms of records of integrated developments of inpatients based on SOAP and Knowing the factors causing incomplete replenishment of integrated development records of inpatients based on SOAP at RST. Soedjono Magelang. Method: The type of this research is descriptive research using qualitative approach. The research design used is case study. Subjects in this study were medical record officer, ward nurse and head of medical record installation. The object of this research is 100 medical records file of inpatients. Data collection techniques with observation, interview and documentation study. For data validation using source triangulation. This research was conducted in medical record installation rooms and inpatient installation. Result: Based on the results of the analysis of 100 medical records records of inpatients in which there is a form of integrated development records of inpatients obtained the percentage of completeness recording based on SOAP by 54% and incomplete recording based on SOAP as much as 46%. Factors that cause incompleteness of filling is Human resources in this case doctors and nurses must have knowledge, competence that includes loyalty, discipline, cooperation and responsibility to improve in the performance of the service to the patient and filling out the complete medical record file, there is no list of abbreviations Is agreed upon and is often used by medical officers who fill in the integrated development records form and there is no instruction on filling in the integrated inpatient development note form. There is no standard operating procedures (SOP) of SOAP recording on the inpatient's integrated development records form.

Kata Kunci : analisis, formulir rawat inap, soap