ANALISIS KELENGKAPAN PENGISIAN BERKAS REKAM MEDIS DI RUMAH SAKIT QUEEN LATIFA YOGYAKARTA BERDASARKAN EP 4 MIRM 9 SNARS 2018

FRISA PAMILA R, Nuryati, S.Far., M.P.H

2019 | Tugas Akhir | D3 REKAM MEDIS DAN INFORMASI KESEHATAN

Latar Belakang: Menurut Kepmenkes 129 tahun 2008 Standar Pelayanan Minimal Rumah Sakit, standar kelengkapan pengisian rekam medis 24 jam setelah selesai pelayanan adalah 100%. Pada Standar Nasional Akreditasi Rumah Sakit dalam standar MIRM 9 disebutkan bahwa berkas rekam medis dievaluasi dan diperbaharui sesuai dengan kebutuhan dan secara periodik. Dari hasil studi dokumentasi terdapat beberapa standar belum terisi lengkap. Tujuan: Tujuan penelitian adalah mengetahui persentase dari ketidaklengkapan pengisian berkas rekam medis, mengetahui faktor penyebab ketidaklengkapan, dan mengetahui upaya yang dilakukan melengkapi rekam medis. Metode: Jenis penelitian adalah deskriptif pendekatan kualitatif dengan rancangan penelitian fenomenologis. Teknik pengambilan data menggunakan wawancara, observasi, dan studi dokumentasi. Uji validasi menggunakan tiangulasi sumber dan teknik. Objek penelitian adalah berkas rekam medis rawat inap pasien dalam satu periode perawatan. Hasil: Persentase kelengkapan rekam medis yang belum mencapai 100% diantaranya standar HPK 5, AP 1.5, ARK 3, PKPO 4, PKPO 4.3, PKPO 7, dan ARK 4.2. Faktor penyebab ketidaklengkapan adalah kesibukan dokter maupun petugas, jumlah formulir rekam medis terlalu banyak, dan SPO belum dibuatkan. Upaya yang dilakukan adalah pengecekan kembali oleh petugas, analisis kelengkapan rekam medis, dan komunikasi. Kesimpulan: Pada standar AP 1.5, PKPO 4, PKPO 7, dan ARK 4.2 belum mencapai 80% sesuai kriteria skor SNARS 2018. Faktor penyebab ketidaklengkapan rekam medis adalah kesibukan dari dokter maupun petugas mengakibatkan ketidaktelitian pengisian rekam medis. SPO pengisian rekam medis belum dibuatkan. Upaya yang dilakukan pengecekan rekam medis dan menjalin komunikasi setiap minggu kepada petugas yang belum mengisi rekam medis lengkap.

Background:. According to Kepmenkes Number 129 2008 Minimum Hospital Serice Standards, medical record completeness 24 hours after completion of service was 100%. In the National Standard of Hospital Accreditation in MIRM 9 standard mentioned that medical records were evaluated and updated as needed and periodically. From the documentation study not fully filled 100%. Objective: To know the percentage of incomplete medical record file filling, to know the factors that affect the incompleteness of the medical record file, and know the efforts made to complete the medical record file. Methods: The type of research was descriptive qualitative approach with phenomenological research design. Techniques of data collection used interviews, observation, and study documentation. For the validation used triangulation source and technique. Object of this research was medical record file of one treatment period. Results: The percentage of completeness of medical record not reached 100% among them are HPK 5, AP 1.5, PKPO 4, PKPO 4.3, PKPO 7, and ARK 4.2. Factors that caused incompleteness was the busyness of doctors and officers. The amount of medical records too many, and SOP that has not been strengthened but has been done socialization. Efforts have been made is re-check by officers, medical record completeness analysis, and communication. Conclusion: However standards of HPK 5, AP 1.5, PKPO 4, PKPO 4.3, PKPO 7, and ARK 4.2 cannot reach 80% according to the score criteria on SNARS 2018. Factors that caused the incompleteness of filling in medical records are the busyness of doctors and employee caused inaccuracy in filling out medical records. In addition, the SOP for filling out the medical record has not been made. Efforts made in completing the filling of medical records are checking medical records and communication in the event of remembrance of employee who have not filled out a complete medical record.

Kata Kunci : Analisis Kelengkapan, Faktor, SNARS 2018, Upaya