ANALISIS KELENGKAPAN ISI PERSETUJUAN TINDAKAN MEDIK (INFORMED CONSENT) BERKAS RAWAT INAP BERDASARKAN STANDAR AKREDITASI PUSKESMAS KRITERIA 7.4.4 DI PUSKESMAS KRETEK BANTUL

CITRA RAMADHANI, dr. Tridjoko Hadianto, DTM&H, M.Kes

2018 | Tugas Akhir | D3 REKAM MEDIS SV

Latar Belakang : Informed consent merupakan persetujuan tindakan medis yang diberikan kepada pasien atau keluarga sebelum diberikan tindakan. Berdasarkan hasil studi pendahuluan, Puskesmas Kretek sudah pernah melakukan akreditasi puskesmas namun ada beberapa item informed consent belum terisi lengkap dan belum sesuai dengan standar akreditasi puskesmas kriteria 7.4.4 EP 4. Tujuan : Mengetahui hasil analisis persentase kelengkapan isi formulir persetujuan medik (informed consent) sesuai standar akreditasi puskesmas kriteria 7.4.4, faktor penyebab ketidaklengkapan pengisian informed consent dan upaya untuk mengatasi faktor penyebab ketidaklengkapan pengisian. Metode : Jenis penelitian deskriptif pendekatan kualitatif dengan rancangan studi kasus. Teknik pengambilan data menggunakan studi dokumentasi, observasi dan wawancara. Uji keabsahan data menggunakan triangulasi teknik dan triangulasi sumber. Hasil : Hasil analisis persentase kelengkapan informed consent berkas rawat inap berdasarkan standar akreditasi, kelengkapan terendah terdapat pada data autentikasi dan kelengkapan pengisian seluruh data yang dinilai hanya mencapai 36,32%. Faktor penyebab ketidaklengkapan informed consent meliputi Man yaitu petugas klinis kurang paham pentingnya pendokumentasian informed consent, hanya fokus terhadap tindakan klinis, tidak melihat kelengkapan pengisiannya; pasien atau keluarga pasien tidak mengisi data secara lengkap; petugas rekam medis belum pernah melakukan analisis kelengkapan pengisian informed consent dan Method yaitu kurangnya sosialisasi SOP. Upaya untuk mengatasi faktor penyebab ketidaklengkapan meliputi sosialisasi SOP, pendekatan kepada petugas, bimbingan dan pembinaan, monitoring dan evaluasi, serta melengkapi pengisian formulir. Kesimpulan : Terdapat ketidaklengkapan pengisian informed consent berkas rawat inap dengan kategori pencapaian elemen penilaian standar akreditasi yaitu terpenuhi sebagian kelengkapannya dan mendapat nilai 5. Kata kunci : Informed consent, persetujuan tindakan medik, analisis kelengkapan, standar akreditasi puskesmas

Background : Informed consent is an agreement of medical action that given to the medical patient before they are given the medical action. Based on the previous research, Puskesmas Kretek have done an accreditation, but there were some informed consent items that have not completed yet and not suitable with the accreditation standard of Puskesmas criterion 7.4.4 EP 4. Objective : The purpose of this study is to know the analysis result of the completeness of informed consent form percentage which suitable with the accreditation standard of Puskesmas criterion 7.4.4, the factors which caused the incompleteness of admission filling in the informed consent and the efforts to overcome the incompleteness of the admission filling. Methods : The methods was descriptive research qualitative appoarch with the case study technique. The data collection technique used study documentation, observation, and interview. The data validation used the technique triangulation and source triangulation. Results : The results of informed consent completeness percentage analysis of in-patient document based on accreditation criterion, the lowest completeness was in the authentication data and the completeness of admission filling which scored only 36,32%. The casual factors of the incompleteness included Man the clinicians were less understand about the importance of informed consent documentation, they only focused on clinical action, they did not see the admission filling completeness; the patient did not fulfill the data completely; the medical recorder had not done an analysis of informed consent completeness, and method the lack of SOP socialization. The efforts to overcome this casual factors of the incompleteness involved the SOP socialization, approach to officer, guidance to officer, monitoring an evaluation, and complete the form filling. Conclusion : There is incompleteness in the admission filling of the informed consent of in-patient with the category of rating element achievement accreditation standard is partly complete and get 5 point. Keywords : Informed consent, agreement of medical action, completeness analysis, accreditation standard of Puskesmas

Kata Kunci : Informed consent, persetujuan tindakan medik, analisis kelengkapan, standar akreditasi puskesmas/Informed consent, agreement of medical action, completeness analysis, accreditation standard of Puskesmas