ANALISIS KELENGKAPAN PENGISIAN BERKAS REKAM MEDIS RAWAT INAP BERDASARKAN ELEMEN PENILAIAN MIRM 13.3 SNARS DI RUMAH SAKIT DKT DR. SOETARTO YOGYAKARTA

RATU EVA K, Dr. Nur Rokhman, S.Si., M.Kom.

2020 | Tugas Akhir | D3 REKAM MEDIS DAN INFORMASI KESEHATAN

Latar Belakang : Rekam medis sebagai bukti tertulis dapat dilihat dari pengisian tanggal, jam, tanda tangan, dan nama. Indikator mutu rekam medis yang baik meliputi kelengkapan isi dan pemenuhan persyaratan hukum. Berdasarkan studi pendahuluan, masih terdapat ketidaklengkapan pengisian tanggal, jam, tanda tangan, dan nama. Hal ini berdampak pada mutu rekam medis, keselamatan pasien, lemahnya rekam medis dihadapan hukum, dan terjadinya malpraktik. Tujuan : Mengetahui presentase kelengkapan pengisian rekam medis rawat inap berdasarkan EP MIRM 13.3 SNARS, faktor penyebab ketidaklengkapan, dan upaya pengendalian ketidaklengkapan. Metode : Jenis penelitian deskriptif pendekatan kualitatif dan rancangan penelitian studi kasus. Teknik pengumpulan data menggunakan teknik wawancara, observasi, dan studi dokumentasi. Subjek penelitian meliputi perawat, dokter, petugas rekam medis dan assembling, serta kepala instalasi rekam medis. Objek penelitian meliputi berkas rekam medis yang kembali pada bulan November-Desember 2019 dan Januari 2020. Uji keabsahan data dengan triangulasi sumber dan triangulasi teknik. Hasil : Hasil analisis kelengkapan rekam medis rawat inap berdasarkan EP MIRM 13.3 SNARS di RS DKT Dr. Soetarto diperoleh kelengkapan pengisian tanggal 72,9%, jam 56,2%, tanda tangan 76,6%, dan nama 72,9%. Penyebab ketidaklengkapan adalah beban kerja, kurangnya ketelitian dan komunikasi, anggaran terbatas, banyaknya item data pada formulir, SPO kelengkapan pengisian belum dilaksanakan sepenuhnya oleh petugas, belum dilakukannya sosialisasi SPO, serta belum adanya stampel nama perawat dan dokter baru. Upaya pengendalian ketidaklengkapan adalah melakukan assembling, analisis, memintakan kelengkapan kepada perawat dan DPJP, meningkatkan komunikasi dan kerjasama, disediakannya anggaran untuk pembelian stampel, membiasakan mengisi rekam medis dengan lengkap, melakukan sosialisasi SPO kelengkapan, serta pengadaan stampel nama perawat dan dokter baru. Kesimpulan : Pengisian rekam medis rawat inap berdasarkan EP MIRM 13.3 SNARS belum terpenuhi lengkap. Faktor penyebab dan upaya pengendalian ketidaklengkapan dapat dilihat dari unsur beban kerja, komunikasi dan kerjasama, ketersediaan anggaran, keefektifan item formulir, serta pengimplementasian SPO. Sebaiknya rumah sakit menerapkan reward dan punishment, mengadakan sosialisasi SPO, mengkaji ulang keefektifan formulir, serta melakukan monitoring dan evaluasi.

Backgrounds : Medical records as written evidence can be seen from the filling in date, time, signature, and name. indicators of good medical record quality include completeness of contents and compliance with legal requirements. Based on the preliminary study, there are incomplete entries in the date, time, signature, and name. this has an impact on the quality of medical records, patient safety, weak medical records before the law, and the occurance of malpractice. Objective : Identify the percentage of completeness of inpatient medical record filling based on elements of MIRM 13.3 assessment of SNARS, factors causing incompleteness, and efforts to control incompleteness. Methods : This type of research uses descriptive qualitative research approaches and case study research designs. Data collection techniques using interview, observation, and documentation studies. Research subjects are nurses, doctors, medical records and assembling, and heads of medical record installations. The object of research includes the medical record file back in November-December 2019 and January 2020. Test the validity of the data by triangulation of sources and triangulation of techniques. Results : The results of inpatient medical record analysis based on elements of MIRM 13.3 assessment of SNARS at RS DKT Dr. Soetarto, the completeness from date 72,9%, time 56,2%, signature 76,7%, and name 72,9%. The causes of incompleteness are workload, lack of accuracy and communication, limited budget, the number of data items on the form, SPO has not been fully implemented by health personnel, SPO socialization has not been done, and there are no name stamp for nurses and new doctors. Efforts to control incompleteness are conducting assembling and analysis, requesting completeness to nurses and doctors, improving communication and cooperation, providing budgets for stamp purchases, getting used to filling medical record completely, conducting SPO socialization, and purchase name stamp for nurses and new doctors. Conclusion : Inpatient medical records filling based on elements of MIRM 13.3 assessment of SNARS are still incomplete. The causes and the efforts to control incompleteness can be seen from the elements of workload, communication and cooperation, budget availability, the effectiveness of form items, and the implementation of SPO. Hospitals should apply reward and punishment, conduct SPO socialization, review the effectiveness of forms, and conduct monitoring and evaluation.

Kata Kunci : Analisis kelengkapan, rekam medis, akreditasi, SNARS / Completeness analysis, medical records, accreditation, SNARS