TINJAUAN PENGELOLAAN KELENGKAPAN DAN KERAHASIAAN REKAM MEDIS BERDASARKAN STANDAR AKREDITASI KRITERIA 8.4.4. PASCA AKREDITASI DI PUSKESMAS PAKUALAMAN

AININA WIDIA LINKA H, Nuryati, S.Far., M.P.H.

2019 | Tugas Akhir | D3 REKAM MEDIS DAN INFORMASI KESEHATAN

Latar Belakang: Akreditasi puskesmas adalah penilaian dan pengakuan yang diberikan lembaga pemerintah untuk menjamin mutu pelayanan. Berdasarkan wawancara, Puskesmas Pakualaman mendapat penilaian "Terakreditasi Madya" pada akreditasi 2017, dan menerima rekomendasi hasil survey pada Desember 2018. Berdasarkan catatan surveyor, terdapat rekomendasi untuk Bab VIII Kriteria 8.4.4 tentang kelengkapan dan kerahasiaan rekam medis. Tujuan: Mengetahui pengelolaan kelengkapan dan kerahasiaan rekam medis berdasarkan standar akreditasi kriteria 8.4.4. menjelang akreditasi tahun 2020 di Puskesmas Pakualaman. Metode: Jenis penelitian yang digunakan adalah deskriptif dengan pendekatan kualitatif. Teknik pengumpulan data dengan wawancara, observasi, dan studi dokumentasi. Hasil: Kelengkapan rekam medis di Puskesmas Pakualaman telah sesuai dengan Surat Keputusan Nomor 188 Tahun 2017 tentang isi rekam medis dan Standar Operasional Prosedur (SOP) penilaian kelengkapan dan ketepatan isi rekam medis nomor SOP/PA/VIII/99/2017, namun belum ada prosedur pengisian rekam medis. Kerahasiaan rekam medis telah sesuai SOP kerahasiaan rekam medis nomor SOP/PA/VIII/100/2017, namun tempat penyimpanannya kurang terjamin karena rekam medis disimpan di lemari terbuka. Sedangkan tindak lanjut Puskesmas Pakualaman masih berupa rencana tindak lanjut, yaitu berencana mengadakan review dokumen, perencanaan tingkat puskesmas, dan perencanaan sarana-prasarana. Kesimpulan: Komponen analisa penilaian kelengkapan belum sesuai dan pelaksanaan kerahasiaan masih kurang rahasia karena terbatasnya sarana dan prasarana, serta belum menindaklanjuti rekomendasi penilaian akreditasi 2017.

Background:Accreditation of public health centers is an assessment and recognition given by government institutions to ensure service quality. Based on interview,Pakualaman health center get "Intermediate Accredited" on accreditation assessment 2017, and the results were received in December 2018. Based on surveyor records, there are recommendations for chapter VIII criteria 8.4.4 concerning the completeness and confidentiality of medical records. Objective:To find out the management of the medical records completeness and confidentiality based on accreditation standard criteria 8.4.4 towards accreditation in 2020 at Pakualaman health center. Method:The type of research that used is descriptive research with qualitative approach. The technique of collecting data is by interview, observation, and documentation study. Result:The completeness in Pakualaman health center is appropriate with the Decree number 188 of 2017 about the contents of medical records and the Standard Operating Procedures number SOP/PA/VIII/99/2017 concerning assessment of the medical records completeness and content accuration, but there is no procedure for medical record filling. Implementation of medical records confidentiality based on Standard Operating Procedures for confidentiality of medical records number SOP/PA/VIII/100/2017. However, the storage area does not guarantee confidentiality because the medical records stored in unlocked cabinet. While follow-up of Pakualaman health center is still in a follow-up plan stages, that is planning to hold a document review, the health center levels planning, facilities and infrastructure planning. Conclusion: The analysis component of medical record completeness assessment hasn't been appropriate and the implementation of medical record confidentiality system still not confidential because of limited facilities and infrastructure, and no follow-up recommendations from accreditation assessment results 2017.

Kata Kunci : Kata Kunci: akreditasi puskesmas, kelengkapan, kerahasiaan, tindak lanjut akreditasi.