TINJAUAN PEMENUHAN ELEMEN PENILAIAN MIRM 13.4 DI RS PRATAMA YOGYAKARTA TERKAIT PERSIAPAN AKREDITASI SNARS

NAILA ULFA TALITHA, Nuryati, S.Far., M.P.H.

2019 | Tugas Akhir | D3 REKAM MEDIS DAN INFORMASI KESEHATAN

Latar Belakang: Rumah Sakit (RS) Pratama Yogyakarta merupakan rumah sakit yang sudah melaksanakan akreditasi pertama kali pada Desember 2018 namun belum mengajukan Bab Manajemen Informasi dan Rekam Medis (MIRM) untuk diakreditasi. Oleh karena itu diperlukan penelitian mengenai review rekam medis yang terdapat pada standar MIRM 13.4 Standar Nasional Akreditasi Rumah Sakit (SNARS). Tujuan: Mengetahui persiapan akreditasi terkait pemenuhan Elemen Penilaian MIRM 13.4 pada Standar Nasional Akreditasi Rumah Sakit di RS Pratama Yogyakarta. Metode: Jenis penelitian adalah penelitian deskriptif kualitatif dan rancangan penelitian fenomenologi. Subjek dalam penelitian ini adalah petugas rekam medis, perawat, dokter, dan Kepala Instalasi Rekam Medis. Objek dalam penelitian ini yaitu Standar Prosedur Operasional (SPO), kebijakan, pedoman rumah sakit, dan formulir rekam medis dalam pemenuhan Elemen Penilaian MIRM 13.4. Teknik pengumpulan data dengan wawancara, observasi, dan studi dokumentasi. Uji keabsahan data dengan triangulasi sumber dan triangulasi teknik. Hasil: Berkas rekam medis yang kembali ke Instalasi Rekam Medis belum dicek kelengkapan isi rekam medisnya dahulu sebelum dikembalikan ke rak penyimpanan. Pemenuhan Elemen Penilaian 1-7 MIRM 13.4 SNARS di RS Pratama Yogyakarta belum terpenuhi seluruhnya. Persiapan akreditasi yang telah dilakukan adalah mempersiapkan dokumen-dokumen yang dibutuhkan seperti SPO, pedoman, dan kebijakan. Kesimpulan: Pelaksanaan review rekam medis di RS Pratama Yogyakarta belum dilakukan. Pemenuhan Elemen Penilaian standar MIRM 13.4 dalam persiapan akreditasi SNARS di Instalasi Rekam Medis belum tepenuhi seluruhnya. Rumah sakit sebaiknya segera membahas mengenai pelaksanaan review rekam medis dan melaksanakan rapat rutin dalam persiapan akreditasi SNARS.

Background: RS Pratama Yogyakarta is a hospital that already carry out accreditation for the first time in December 2018 however have not already submitted Information Management and Medical Record (MIRM) chapter to be accredited. Therefore it is needed research concerning medical record review that found on MIRM 13.4 National Standards for Hospital Accreditation (SNARS) standard. Purpose: To understand accreditation preparation concerned fulfilment of the evaluation element of MIRM 13.4 in SNARS at RS Pratama Yogyakarta. Methods: The type of research is qualitative descriptive research and phenomenology research design. Subjects in this study were medical record officers, nurses, doctors, and a head of medical record installation. The objects of this research are Standard Operationg Procedure (SOP), the policy, hospital guidelines, and medical record forms in fulfilment of evaluation elements of MIRM 13.4. The technique of collecting data are interviews, observation, and study of documentations. The validity test of the data using source triangulation and technical triangulation.. Result: Medical record files which return to the medical record installation have not been checked the content completeness of the medical record before returned to storage shelf. The 1-7 fulfillment of the evaluation elements MIRM 13.4 SNARS at RS Pratama Yogyakarta have not fully achieved yet. Accreditation preparations that have been done is preparing of the documents that needed such as SOP, guidelines, and policy. Conclusion: The implementation of a medical record review at RS Pratama Yogyakarta have not been done. The fulfillment of standard evaluation elements of MIRM 13.4 in SNARS accreditation preparation at Medical Record Installation have not fully achieved yet. The hospital should immediately discuss the implementation of the medical record review and carry out routine meetings in preparation for SNARS accreditation.

Kata Kunci : Persiapan akreditasi, standar MIRM 13.4, review rekam medis