KUALITAS RESUME MEDIS (DISCHARGE SUMMARY) PADA PASIEN RAWAT INAP JKN DI RSUD DOKTER SOEDARSO PROPINSI KALIMANTAN BARAT
RANNI MURTININGRUM, Prof. dr. HARI KUSNANTO, Dr.PH
2019 | Tesis | MAGISTER ILMU KESEHATAN MASYARAKATLatar Belakang: Resume medis yang tidak lengkap akan berdampak pada kelancaran klaim pasien JKN. Periode Januari-April 2017 sebanyak 970 dokumen klaim JKN pasien rawat inap di RSUD Dokter Soedarso Propinsi Kalimantan Barat dikembalikan ke rumah sakit. Penelitian ini bertujuan menganalisis kualitas resume medis pasien rawat inap JKN. Metode: Penelitian menggunakan jenis penelitian kualitatif. Pengumpulan data dilakukan dengan observasi, wawancara mendalam dan focus group discussion (FGD). Hasil: Resume medis lengkap sebanyak 48% dengan komponen paling tidak sesuai adalah diagnosa sekunder (63%) dan tindakan (61%). Ketepatan waktu pengisian resume medis 71%. Analisis HOT-FIT dari faktor human: pengetahuan tentang resume medis belum sampai pada level aplikasi dan memahami dampaknya, beban kerja dokter dengan banyak pasien ditambah tidak adanya reward/punishment sehingga tidak ada dorongan untuk memotivasi pengisian resume medis yang baik. Faktor organisasi: SOP belum disosialisasikan dan petunjuk teknis pengisian resume medis tidak relevan dengan formulir resume medis. Belum ada tindak lanjut atas laporan analisis kelengkapan dokumen rekam medis, belum ada monitoring/evaluasi khusus terhadap pengisian resume medis dan belum ada tim kendali mutu kedali biaya di rumah sakit. Kebijakan melampirkan fotokopi hasil pemeriksaan penunjang pada dokumen klaim menambah beban anggaran rumah sakit. Faktor teknologi: resume medis masih manual dan formulir resume medis belum mudah digunakan. Kesimpulan: Kualitas resume medis belum lengkap, akurat dan tepat waktu disebabkan interaksi yang belum baik pada faktor human, organisasi dan teknologi. Perbaikan melalui teknologi informasi dengan menerapkan rekam medis elektronik diharapkan dapat memudahkan proses pengisian resume medis. Kata Kunci: kualitas resume medis, lengkap, akurat, tepat waktu, HOT-FIT
Background: Incomplete discharge summary will have an impact on the process of claiming national health insurance patients. The period January-April 2017 as many as 970 JKN claims documents for hospitalized patients at the Dokter Soedarso General Hospital, West Borneo Province, were returned to the hospital. This study aims to analyze the quality of discharge summary for national health insurance hospitalized patients. Methods: This is qualitative research. Data collection is done by observation, in-depth interviews and focuses group discussion (FGD). Results: A complete discharge summary of 48% with the least suitable component was secondary diagnosis (63%) and procedure (61%). Timeliness of medical resume filling is 71%. HOT-FIT analysis of human factors: knowledge of discharge summaries has not arrived at the application level and understands the impact, the workload of doctors with many patients, and the absence of reward/punishment so there is no encouragement to motivate a good discharge summary. Organizational factors: standard operating procedures have not been socialized and technical instructions for filling out discharge summary are irrelevant to discharge summary forms. There is no follow-up on the analysis report of the completeness of the medical record documentation, there is no specific monitoring/evaluation of filling out the discharge summary and there is no quality control team at the hospital. The policy to attach photocopies of the results of the investigation into the claim document adds to the burden on the hospital budget. Technological factors: discharge summary are still manual and discharge summary forms that are not easy to use. Conclusions: Quality of discharge summary is incomplete, inaccurate, and delayed due to unfavorable interactions in human, organizational, and technological factors. Improvement through information technology by implementing electronic medical records are expected to facilitate the process of filling out the discharge summaries. Keyword: discharge summary quality, complete, accurate, timely, HOT-FIT
Kata Kunci : kualitas resume medis,lengkap,akurat,tepat waktu,HOT-FIT
