EVALUASI KINERJA PETUGAS REKAM MEDIS BERDASARKAN STANDAR PELAYANAN MINIMAL DI RSKB SINDUADI

ANISSA SYAHDRINA, M. Syairaji, S.K.M., M.P.H.

2019 | Tugas Akhir | D3 REKAM MEDIS DAN INFORMASI KESEHATAN

ABSTRAK Latar Belakang : Analisis kuantitatif berkas rekam medis di RSKB Sinduadi yang belum dilakukan menyebabkan persentase kelengkapan berkas rekam medis tidak diketahui dengan tepat. Kelengkapan berkas rekam medis belum begitu diperhatikan karena RSKB Sinduadi belum bekerjasama dengan BPJS atau pihak asuransi lainnya sehingga kelengkapan berkas rekam medis masih rendah sedangkan kelengkapan berkas rekam medis menjadi syarat klaim dari pihak asuransi. Selain itu, penyediaan berkas rekam medis masih lama. Evaluasi kinerja petugas rekam medis belum pernah dilakukan di RSKB Sinduadi. Evaluasi kinerja penting dilakukan untuk mengetahui prestasi kerja yang dicapai setiap pegawai dan berguna untuk pengambilan keputusan. Tujuan : Mengevaluasi kinerja petugas rekam medis berdasarkan standar pelayanan minimal di RSKB Sinduadi Metode : Jenis penelitian ini analitik dengan pendekatan kuantitatif dan deskriptif dengan pendekatan kualitatif serta rancangan cross sectional dan studi kasus. Subjek penelitian yaitu satu perawat, satu dokter, dua petugas rekam medis, dan direktur rumah sakit. Objek penelitian yaitu berkas rekam medis pasien, standar operasional prosedur pengisian dan analisis berkas rekam medis, serta petugas rekam medis. Teknik pengambilan data yaitu observasi, wawancara, dan studi dokumentasi. Hasil : Persentase kelengkapan pengisian berkas rekam medis sebesar 54 persen sedangkan persentase kelengkapan informed consent sebesar 56 persen. Rata-rata waktu penyediaan berkas rekam medis rawat jalan sebesar 4,25 menit sedangkan rawat inap 13,54 menit. Faktor yang mempengaruhi kinerja petugas rekam medis antara lain machine, man, method, dan environtment. Kesimpulan : Persentase kelengkapan berkas rekam medis tidak memenuhi standar pelayanan minimal yang sedangkan rata-rata waktu penyediaan berkas rekam medis sudah memenuhi standar pelayanan minimal menurut Kepmenkes nomor 129 tahun 2008.

ABSTRACT Background: The quantitative analysis activity of the medical record file in RSKB Sinduadi has not been done causing the percentage of completeness of the medical record file is not known correctly. The completeness of the medical record file has not been noticed because RSKB Sinduadi has not yet collaborated with BPJS or other insurance parties so that the completeness of the medical record file is still low while the completeness of the medical record file becomes the claim requirement of the insurance party. In addition, the provision of medical record files is still long. Evaluation of the performance of medical records officers has never been done at RSKB Sinduadi. Performance evaluation is important to determine the work performance achieved by each employee and is useful for decision making. Objective: To evaluate the performance of medical personnel based on minimum service standards at RSKB Sinduadi Method: This type of research is descriptive using qualitative and design case studies. The research subjects were one nurse, one doctor, two medical record officers, and the hospital director. The research objects are medical records, standard operating procedures for filling out and analyzing medical records, and medical record officers. Data collection techniques are observation, interview, and documentation study. Results: Percentage of completeness of filling in medical record documents is 54 percent while percentage of completeness of approval information is 56 percent. The average time of providing outpatient medical records is 4.25 minutes while inpatient is 13.54 minutes. Factors that influence the performance of medical records include machinery, people, methods, and the environment. Conclusion: The percentage of the completeness of the medical record file does not meet the minimum service standard, whereas the average time for the provision of the medical record file has met the minimum service standard according to Kepmenkes number 129 of 2008.

Kata Kunci : Evaluasi, kinerja, rekam medis, standar pelayanan minimal / Evaluation, performance, medical records, minimum service standards