PERANCANGAN FORMULIR RAWAT JALAN, FORMULIR PENGKAJIAN AWAL DAN STANDAR OPERASIONAL PROSEDUR DI PUSKESMAS GONDOKUSUMAN 1 KOTA YOGYAKARTA

DOMINIKA VALENTINA A, Marko Ferdian Salim, S.K.M. M.P.H.

2019 | Tugas Akhir | D3 REKAM MEDIS DAN INFORMASI KESEHATAN

Latar Belakang: Rekam medis di Puskesmas Gondokusuman 1 Yogyakarta masih berupa buku sehingga banyak formulir terbuang dan belum memenuhi kelengkapan item. Sementara itu, rencana pengubahan rekam medis guna reakreditasi dikhususkan untuk Formulir Rawat Jalan dan Pengkajian Awal terkendala akibat kekurangan tenaga dan kemampuan SDM yang terbatas dalam mendesain formulir. Peneliti kemudian tertarik melakukan perancangan formulir guna mendukung Huffman (1994) yang menyebutkan bahwa salah satu objek kontrol formulir yaitu pembuatan dan penggunaan formulir secara ekonomis. Tujuan: Merancang Formulir Rawat Jalan, Formulir Pengkajian Awal dan SOP Pengisiannya di Puskesmas Gondokusuman 1 Yogyakarta dengan mempertimbangkan aspek desain formulir menurut Huffman (1994) dan mengacu pada standar akreditasi puskesmas. Metode: Perancangan Formulir Rekam Medis menggunakan langkah desain formulir sesuai RCH Forms Committee (2006). Hasil: Formulir terpilih menggunakan kertas HVS 80 gram, ukuran F4 (21,59 x 35,56 cm). Isi formulir berdasarkan aspek desain formulir dan mengacu pada format SOAP (Subjective, Objective, Assessment, and Planning) serta standar akreditasi. Penyusunan hasil akhir SOP disesuaikan dengan formulir terpilih. Kesimpulan: Hasil desain Formulir Rawat Jalan, Formulir Pengkajian Awal dan SOP Pengisian Formulir telah memenuhi aspek desain formulir dan standar akreditasi serta disesuaikan kebutuhan petugas. Puskesmas Gondokusuman 1 Yogyakarta sebaiknya mengimplementasikan hasil rancangan tersebut guna reakreditasi yang akan dilakukan.

Background: The medical records at Puskesmas Gondokusuman 1 Yogyakarta are still in the books so that many forms are wasted and have not fulfilled the complete items. In the meantime, plans to change medical records for re-accreditation are specifically for Outpatient Forms and Early Assessment is constrained due to lack of manpower and limited human resource capacity in designing forms. Then, the researcher interest to designed the form to support Huffman (1994) which stated that one of the objects of form control was making and using forms economically. Objective: Design Outpatient Form, Assessment Form and SOP in Puskesmas Gondokusuman 1 by considering aspects of form design according to Huffman (1994) and referring to the standard of accreditation of the puskesmas. Methods: Designing the Medical Record Form using the form design steps according to the RCH Forms Committee (2006). Results: The form is selected using 80 gram HVS paper,F4 size (21.59 x 35.56 cm). Form contents based on aspects of form design and refer to SOAP (Subjective, Objective, Assessment, and Planning) formats, and accreditation standards. The last result of SOP depend on the selected form. Conclusion: The results of the Outpatient Form design and the Preliminary Assessment Form and the SOP for Form Completion have met the design aspects and accreditation standards of and adjusted the needs of the officers.Puskesmas Gondokusuman 1 Yogyakarta should implement the results of the design to re-accreditation to be carried out.

Kata Kunci : Desain Formulir, Pengkajian Awal, Rawat Jalan, Standar Operasional Prosedur