PELAKSANAAN PENGISIAN DAN KELENGKAPAN RESUME MEDIS BERDASARKAN ELEMEN PENILAIAN MIRM 15 SNARS DI RSU AT-TUROTS AL-ISLAMY

RADINDA AULIA W, Nuryati, S.Far., M.P.H

2019 | Tugas Akhir | D3 REKAM MEDIS DAN INFORMASI KESEHATAN

Latar Belakang : Resume medis rawat inap merupakan bukti tertulis yang berisi ringkasan pelayanan pasien selama dirawat inap. Ketidaklengkapan resume dapat berdampak pada proses klaim dan hasil akreditasi sedangkan RSU At-Turots Al-Islamy belum pernah melaksanakan akreditasi dan sedang mempersiapkan akreditasi SNARS. Dalam SNARS terdapat standar MIRM 15 yang berkaitan dengan penilaian resume medis. Tujuan : Penelitian bertujuan untuk mengetahui pelaksanaan pengisian, kelengkapan item, persentase kelengkapan, dan upaya petugas rekam medis untuk mengatasi ketidaklengkapan terhadap pengisian resume medis berdasarkan Elemen Penilaian MIRM 15 SNARS. Metode : Jenis penelitian yang digunakan adalah penelitian deskriptif dengan pendekatan kualitatif dan rancangan penelitian studi kasus. Teknik pengumpulan data menggunakan teknik wawancara, observasi, dan studi dokumentasi. Hasil : RSU At-Turots Al-Islamy belum memiliki SPO pengisian resume. Formulir resume belum memenuhi EP 2 MIRM 15 karena belum terdapat item untuk menuliskan indikasi pasien dirawat inap. Hasil analisis kelengkapan resume berdasarkan 6 EP MIRM 15 SNARS di RSU At-Turots Al-Islamy yaitu EP 1 62,9%, EP 2 55,2%, EP 3 46,7%, EP 4 89,5%, EP 5 21,9%, dan EP 6 54,3%. Upaya pengendalian ketidaklengkapan faktor man dengan koordinasi dengan perawat, assembling & analisis kelengkapan, dan melakukan permintaan kelengkapan kepada DPJP. Unsur method dengan pembuatan SPO mengenai kegiatan assembling&analisis. Kesimpulan : Pengisian serta item dalam formulir resume berdasarkan Elemen Penilaian MIRM 15 SNARS masih belum lengkap. Upaya petugas rekam medis mengatasi ketidaklengkapan meliputi unsur Man dan Method.

Background : Discharge Summary Form is written evidence about inpatient services. The incompleteness of the discharge summary affects the insurance claim process and the result of accreditation while RSU At-Turots Al-Islamy has never been done accreditation before and still preparing for the accreditation. In the SNARS accreditation there are MIRM 15 Standard relating to discharge summary assessment. Objective : This study aims to identify the implementation of charging, the suitability of items, the percentage of completeness, and the effort to control incompleteness of discharge summary done by medical recorder at RSU At-Turots Al-Islamy. Methods : The type of this research is descriptive research with qualitative approach and case study as the research design. The data was taken by interview, observation and documentation studies. Results : RSU At-Turots Al-Islamy do not have Standard Operating Procedure(SOP) related to the fulfillment of discharge summary (form). Discharge Summary Form not fulfilling EP 2 MIRM 15 because there is no item to write indiction of patient being hospitalized. The result about analysis of completeness of discharge summary based on elements of MIRM 15 assessment of SNARS at RSU At Turots Al-Islamyis EP 1 62,9%, EP 2 55,2%, EP 3 46,7%, EP 4 89,5%, EP 5 21,9%, dan EP 6 54,3%. Medical recorder efforts to overcome incompleteness from man element by coordination with nurses, assembling & completeness analysis, and returning the documents to the medical specialist in the ward. From method element by making SPO about assembling&completeness analysis. Conclusion : Fullfilment and item of discharge summary corresponding SNARS element MIRM 15 is not complete. Medical Recorder effort to control incompleteness of discharge summary include: Man and Method Element.

Kata Kunci : Akreditasi, Analisis Kelengkapan, Resume, SNARS