PERANCANGAN FORMULIR PASIEN GAWAT DARURAT DAN STANDAR OPERASIONAL PROSEDUR (SOP) PENGISIAN FORMULIR PASIEN GAWAT DARURAT DI PUSKESMAS GAMPING II

ANITA KRISNIYANTI, Heru Subekti, S.Kep., M.P.H.

2020 | Tugas Akhir | D3 REKAM MEDIS DAN INFORMASI KESEHATAN

Latar Belakang : Pelayanan gawat darurat merupakan pelayanan dasar di Puskesmas Gamping II. Pada tahun 2018, Puskesmas Gamping II telah melaksanakan akreditasi dan mendapat saran terkait kriteria pengkajian awal untuk membuat formulir pasien gawat darurat sebagai dokumentasi pengkajian kegawatdaruratan, khususnya triase. Pembuatan formulir terkendala karena keterbatasan SDM dalam merancang formulir. Selain itu, pendokumentasian yang masih tergabung dengan formulir rawat jalan dan belum adanya SOP pengisian formulir pasien gawat darurat menyebabkan output pendokumentasian bervariasi, kurang lengkap, dan tidak berkesinambungan. Tujuan : Merancang formulir pasien gawat darurat dan SOP pengisian formulir pasien gawat darurat di Puskesmas Gamping II. Metode : Metode perancangan formulir pasien gawat darurat dan SOP Pengisian formulir pasien gawat darurat menggunakan metode dan langkah pengembangan formulir menurut RCH Forms Committee 2006. Hasil : Formulir terpilih menggunakan kertas HVS 80 gram dengan ukuran kertas F4 (21.5 cm x 33 cm). Format formulir berdasarkan aspek desain formulir dan isinya mengacu pada Permenkes 269 Tahun 2008 dan mempertimbangkan tatalaksana kegawatdaruratan pada Permenkes 47 Tahun 2018 tentang pelayanan kegawatdaruratan. Hasil akhir dari SOP menyesuaikan dengan formulir terpilih yang mengacu pada pedoman penyusunan dokumen akreditasi tahun 2017. Kesimpulan : Hasil perancangan formulir pasien gawat darurat dan SOP pengisian formulir pasien gawat darurat telah memenuhi kebutuhan puskesmas, aspek desain formulir dan standar akreditasi serta tidak terdapat revisi setelah uji coba dan sebaiknya puskesmas segera mengimplementasikan hasil rancangan yang telah dibuat.

Background : Emergency care is the basic services in Puskesmas Gamping II. In 2018, Puskesmas Gamping II had carried out accreditation and received advice regarding the initial assessment criteria to make emergency medical record form for documentation on the emergency assessment process especially triage. Form creation was constrained due to the limitations of human resource capacity in designing form. In addition, emergency medical record is still the same with outpatient care and the absence of SOPs for filling emergency medical record form cause the documentation output varies, incomplete, and inadequate. Objective : To design emergency medical record form and SOP for filling emergency medical record form in Puskesmas Gamping II. Methods : The method for designing the emergency medical record form and SOP for filling emergency medical record form according to the methods and steps of the RCH Forms Committee 2006. Results : The emergency medical record form was selected using 80 gram HVS paper and the size is F4 (21.5 cm x 33 cm). The format of the form based on form design aspects and the content based on Permenkes 269 of 2008 and consider the management of emergency patient in Permenkes 47 of 2018. The final results of the SOP adjusts to the selected forms that refer the guidelines of the preparation documents for accreditation 2017. Conclusion : The results of the emergency medical record form and the SOP for filling the emergency medical record form have met the needs of the puskesmas, aspects of form design, accreditation standards, no revision after trial step and also the design results should be immediately implemented.

Kata Kunci : Kata Kunci : Formulir gawat darurat, SOP, perancangan formulir, perancangan SOP, formulir rekam medis