KELENGKAPAN PENGISIAN RESUME MEDIS DENGAN PENDEKATAN METODE HOT FIT DI RSUD CEMPAKA PUTIH

DEWI R ANGGRAINI, dr. Lutfan Lazuardi, M.Kes. Ph.D.; DR. dr. Andreasta Meliala, DPH, Mkes, MAS

2017 | Tesis | S2 Ilmu Kesehatan Masyarakat

Latar belakang: Resume medis adalah ringkasan dari rekam medis yang dibuat oleh dokter yang melakukan perawatan pasien. Resume medis memiliki banyak manfaat, salah satunya digunakan sebagai pendukung berkas klaim pasien JKN ke BPJS. Pada tahun 2016, RSUD Cempaka Putih mengirimkan 5.113 (100%) berkas resume medis ke BPJS, dimana 2.119 berkas (41.4%) dikembalikan dan 156 berkas (3.1%) dinyatakan tidak layak. Tujuan: Menganalisa kelengkapan pengisian resume medis dengan mengeksplorasi faktor-faktor yang mempengaruhi kelengkapan pengisian resume medis meliputi human (manusia), organization (organisasi) dan technology (teknologi) di RSUD Cempaka Putih. Metode: Menggunakan metode kualitatif, data diambil dengan cara observasi, wawancara mendalam (in depth interview) dan Focus Group Discussion (FGD). Hasil dan pembahasan: Karakteristik responden didominasi usia 31-36 tahun (50%). Jenis kelamin didominasi perempuan (80%), pendidikan didominasi dokter spesialis (50%), dan status pekerjaan adalah non PNS (70%). Hasil penelitian ditemukan kelengkapan pengisian resume medis: 46% dan tidak lengkap 54%. Kelengkapan pengisian resume medis untuk pasien rawat jalan : 49% dan rawat inap: 24%. Ditemukan bahwa gambaran kelengkapan pengisian resume medis sesuai analisis HOT-Fit dari aspek: Human (manusia): Pengetahuan tentang resume medis pada tahap tahu belum sampai pada pemahaman yang utuh, sintesa atau memahami dampaknya. Tidak adanya SPO menjadi salah satu penyebab ketidaklengkapan resume medis. Motivasi DPJP pada level yang baik karena merupakan bentuk tanggung jawab pekerjaan dan tidak memerlukan reward dalam bentuk uang tetapi peningkatan kompetensi. Dari Aspek Organisasi: kepemimpinan kurang tegas dalam pelaksanaan kebijakan dan tidak adanya pemantauan kinerja bawahan. Diharapkan adanya supervisi secara berkala. Faktor tehnologi: Rekam medis masih manual sehingga respon time pengiriman berkas ke poliklinik lama. Berkas resume medis tidak mudah digunakan. Diharapkan adanya perbaikan dalam sistem informasi rekam medis yang didukung oleh teknologi yang memadai. Kesimpulan: Berdasarkan hasil penelitian di atas maka dapat disimpulkan bahwa: gambaran kelengkapan pengisian resume medis di RSUD Cempaka Putih masih belum lengkap utamanya pada pengisian identitas. Hal ini disebabkan karena: interaksi yang belum baik pada aspek Human (pengetahuan dan motivasi masih rendah), Organization (tidak adanya sosialisasi SPO dan supervisi) dan Technology (format resume medis yang tidak mudah digunakan, beberapa kolom resume medis terlalu kecil, waktu pengiriman berkas yang lama). Oleh karena itu perbaikan melalui teknologi menjadi prioritas bagi RSUD Cempaka Putih dengan menerapkan Electronic Medical Record (EMR) yang dapat memudahkan proses pencarian, penulisan, serta penyimpanan berkas resume medis.

Background: Discharge summary is a summary of a medical record created by a physician performing patient treatments. Discharge summary has many benefits, one of which is used as a supporting claim file of JKN patients to BPJS. In 2016, RSUD Cempaka Putih sent 5,113 (100%) discharge summary files to BPJS, where 2,119 files (41.4%) were returned and 156 files (3.1%) declared not eligible for processing. Objective: To analyze the completeness of discharge summary by exploring the factors that affect the completion of discharge summary in terms of human, organization and technology in RSUD Cempaka Putih. Method: By using qualitative method, the data is taken by observation, in depth interview and Focus Group Discussion (FGD) Results and discussion: Characteristics of respondents age was mainly 31-36 years old (50%), majority gender women (80%), majority education was specialist doctors (50%), and the employment status was a non civil servant (70%). The study were resulted that the complete discharge summary were: 46% and the incomplete were 54%. Discharge summary completeness for outpatients were: 49% and for hospitalization were: 24%. It was found that the description of the discharge summary completeness filling inline with the HOT-Fit analysis on the aspect of : On Human terms: the discharge summarys knowledge were not at the level of the intact knowledge to be able to synthezed and provide comprehensive understanding on its impact. The non availability of SOP was also considered as one of the causes of incomplete discharge summary. The DPJPs motivation was considered at good level as it understands the filling of discharge summary as a job responsibility and does not require reward in the form of money but it is considered as competence improvement. On the Organizational terms: the leadership was considered less assertive in the implementation of the policy and provide no performance monitor of subordinates. It is still needs periodic supervision. On Technological terms: the medical records process are conducted manually, it need longger time to send the file to the polyclinic. The discharge summary file is not easy to use. Therefore to provide the discharge summary system, the medical record information system needs to be overhauled by using an adequate technology solution. Conclusion: Based on the above research it can be concluded that: the discharge summary completeness at RSUD Cempaka Putih mainly still lack on filling the identity either for its outpatient and inpatient. This is due to the relationship DPJP Human (The knowledge and motivation still low), Organization (There is no socialization of SOP and supervision) and Technology (discharge summary format is not user friendly, some of column are too small, long time to deliver the documents). Therefore, the improvement through technology becomes a priority for RSUD Cempaka Putih by applying Electronic Medical Record (EMR) which can facilitate the process of searching, writing, and storing medical resume file while at the same time provide training and supervision to improve the discharge summary completeness filling.

Kata Kunci : Resume medis, metode HOT-Fit, Medical record, HOT-fit method