Perancangan Formulir Rekam Medis Di Puskesmas Berbah Sleman

ANGGORO FAJAR K, Marko Ferdian Salim, S.K.M., M.P.H.

2019 | Tugas Akhir | D3 REKAM MEDIS DAN INFORMASI KESEHATAN

Latar Belakang :Puskesmas Berbah dalam melaksanakan pelayanan kesehatan telah melakukan pendokumentasian rekam medis pasien, tetapi masih belum terdapat formulir khusus untuk pelayanan gawat darurat sehingga setiap pasien yang dilayani di Instalasi Gawat Darurat maka akan didokumentasikan ke dalam formulir rawat jalan. Selain itu Puskesmas Berbah memiliki formulir rawat jalan dan persetujuan tindakan yang masih belum sesuai dengan aspek desain formulir dan peraturan yang ada, maka dari itu perlu dilakukannya redesain formulir rawat jalan dan persetujuan tindakan serta perancangan formulir gawat darurat. Tujuan: Menghasilkan rancangan formulir rawat jalan, gawat darurat dan persetujuan tindakan dengan menekankan aturan yang ada serta aspek desain formulir. Metode:Perancangan formulir rekam medis di Puskesmas Berbah ini menggunakan tahapan perancangan formulir sesuai dengan RCH Form Commite (2006). Pengumpulan data dengan tehnik wawancara, observasi, studi dokumentasi dan Focus Group Discussion. Hasil: Perancang membuat dua alternatif formulir yang kemudian di presentasikan ke informan sekaligus memberi kesempatan informan untuk memilih alternatif formulir dengan hasil formulir terpilih, formulir rawat jalan alternatif satu, gawat darurat alternatif dua, dan informed concent alternatif dua. Kesimpulan:Puskesmas Berbah belum memiliki formulir tersendiri untuk pasen gawat darurat serta formulir rawat jalan dan persetujuan tindakan yang belum sesuai dengan aturan yang ada, dari hal tersebut sebaiknya puskesmas berbah melakukan desain ulang formulir.

Background: Berbah health center in carrying out health services has documented the patient's medical records, but there is still no specific form for emergency services so that each patient served in the emergency installation will be documented with the outpatient form . In addition, the Berbah health care has an outpatient form and informed concent form that are still not in accordance with the existing forms and regulations of aspect design, therefore it is necessary to redesign the outpatient form with approval of action and design an emergency form. Objective: Produce an outpatient, emergency and informed concent form design by emphasizing existing rules and form design aspects. Method: The designing of the medical record form at Berbah primary health center used the form design phases in accordance with RCH Form Committee (2006). The data collected by doing interview, observation, documentation study and Focus Group Discussion techniques. Results: The designer made two alternative forms then presented to informants while giving the opportunity for informants to choose alternative forms with the results of the selected forms, alternative one outpatient form, two alternative emergency, and two alternative informed concent. Conclusion: Berbah health center does not have separate form for emergency patients and outpatient forms with informed concent that are not in accordance with the existing regulations, from the result it is recommended that the health center have to redesign the form.

Kata Kunci : Desain formulir, gawat darurat, informed concent, rawat jalan, rekam medis / emergency department, design form, informed concent medical, record, outpatient care.