EVALUASI PERSIAPAN RE-AKREDITASI MENGENAI PENYIMPANAN DAN PEMROSESAN REKAM MEDIS BERDASARKAN KRITERIA 8.4.3 DAN 8.4.4 ELEMEN PENILAIAN 1 DI PUSKESMAS WEDI KLATEN

NIA KUSUMAWATI S P, Angga Eko Pramono, S.K.M., M.P.H

2020 | Tugas Akhir | D3 REKAM MEDIS DAN INFORMASI KESEHATAN

Latar Belakang: Pemrosesan rekam medis Puskesmas Wedi pernah mendapat komplain dari pasien karena kesalahan identifikasi pasien. Pada penyimpanan rekam medis hampir setiap hari terdapat kejadian misfile. Selain itu, terdapat persentase ketidaklengkapan pendokumentasian formulir pelayanan sebanyak 10,36% dan 18% ketidaklengkapan pada informed consent. Puskesmas juga mendapat catatan dari surveyor mengenai ketersediaan dokumen regulasi terkait kriteria 8.4.3 dan 8.4.4 EP 1. Tujuan: Mengetahui persiapan re-akreditasi berdasarkan Standar Akreditasi Kriteria 8.4.3 dan 8.4.4 EP 1 di Puskesmas Wedi. Metode: Jenis penelitian ini deskripstif dengan pendekatan kualitatif. Subjek penelitian ini yaitu ketua akreditasi, ketua pokja UKP, dua petugas medis, dua perekam medis, koordinator rekam medis, dan kepala tata usaha sedangkan objek yaitu persiapan terkait kriteria 8.4.3 dan 8.4.4 EP 1. Penelitian ini dilakukan di Puskesmas Wedi pada bulan Februari-Maret 2020. Pengumpulan data dilakukan dengan observasi, wawancara, dan studi dokumentasi. Uji keabsahan data menggunakan triangulasi sumber dan teknik. Hasil: Proses identifikasi pasien dan pendokumentasiannya belum optimal sehingga berdampak terjadinya duplikasi rekam medis. Pengelolaan penyimpanan rekam medis belum optimal karena keterbatasan jumlah dan format tracer, belum adanya kode warna, dan pelaksanaan pemusnahan belum sesuai dengan aturan yang berlaku. Pelaksanaan pengisian rekam medis belum optimal, terutama kasus KIA. SK dan SOP Penyimpanan dan Isi Rekam Medis belum dilakukan revisi dan isinya belum sesuai. Kesimpulan: Persiapan re-akreditasi kriteria 8.4.3 dan 8.4.4 EP 1 masih perlu adanya perbaikan yaitu dengan memperbaiki regulasi yang baku agar proses identifikasi pasien, proses penyimpanan dan pelaksanaan pengisian rekam medis dapat terlaksana sesuai standar.

Background: Processing of medical records at Wedi Primary Health Center has received complaints from patients due to the misidentification of patients. In storing medical records almost every day there is a misfile event. Also, there was a percentage of incompleteness in documenting forms of 10.36% and 18% of incompleteness in informed consent. Besides, the surveyor also received notes regarding the availability of regulatory documents related to criteria 8.4.3 and 8.4.4 EP 1. Objective: To understand the preparation for re-accreditation based on Accreditation Standards Criteria 8.4.3 and 8.4.4 EP 1 at Wedi Primary Health Center. Methods: In this research, the descriptive studies were used with a qualitative approach. The subjects of this study were the head of accreditation, the head of the UKP working group, two medical officers, two medical record, the medical record coordinator, and the head of administration while the object was related criteria 8.4.3 and 8.4.4 EP 1. This research was conducted at Wedi Primary Health Center in the month of February-March 2020. This research used observation, interviews, and study documentation. Test the validity of the data using source and technique triangulation. Result: The process of identifying patients and documenting is not optimal so that it results in duplication of medical records. Management of medical record storage is not optimal because of the limited number and format of tracers, the absence of color-coding, and the implementation of destruction is not by applicable regulations. The implementation of filling medical records is not optimal, especially in KIA. SK and SOP for Storage and Contents of Medical Records have not been revised and the contents are not appropriate. Conclusion: Preparation for re-accreditation of criteria 8.4.3 and 8.4.4 EP 1 still needs improvement, namely by improving standardized regulations so that the process of identifying patients, the storage process, and the implementation of filling medical records can be carried out according to standards. Keywords: identification, storage, preparation for re-accreditation, medical records

Kata Kunci : Kata Kunci: identifikasi, penyimpanan, persiapan re-akreditasi, rekam medis