ANALISIS KELENGKAPAN PENGISIAN FORMULIR RESUME MEDIS PASIEN RAWAT INAP BERDASARKAN ELEMEN PENILAIAN MIRM 15 SNARS EDISI 1.1 DI RUMAH SAKIT ISLAM (RSI) SAKINAH MOJOKERTO

FAZRUL FALAQ, Nuryati, S.Far., M.P.H.

2020 | Tugas Akhir | D3 REKAM MEDIS DAN INFORMASI KESEHATAN

Latar Belakang: Ketidaklengkapan pengisian formulir resume medis dapat berdampak pada pelayanan klaim asuransi dan dapat menyebabkan rendahnya penilaian terhadap kelengkapan rekam medis sehingga menurunkan mutu pelayanan rumah sakit. Dari hasil studi pendahuluan diketahui bahwa 29 formulir dari 87 formulir resume medis rawat inap di RSI Sakinah Mojokerto yang pengisiannya belum lengkap. Tujuan: Mengetahuii persentase kelengkapani pengisian formuliri resume medis pasien rawati inap berdasarkan elemen penilaian MIRM 15 SNARS Edisi 1.1 di RSI Sakinah Mojokerto dan Mengetahui ketercapaian elemen penilaian MIRM 15 di Rumah RSI Sakinah Mojokerto. Metode: Jenis penelitian deskriptif kualitatif dengan rancangan studi kasus. Subjek penelitian berjumlah 5 orang, terdiri dari 2 petugas rekam medis, 2 perawat dan 1 dokter. Objek penelitian adalah 100 lembar formulir resume medis. Teknik pengumpulan data studi observasi, studi dokumentasi dan wawancara. Uji keabsahan data menggunakan triangulasi sumber. Hasil: Hasil analisis kelengkapan pengisian resume medis berdasarkan review identifikasi pasien 54%, autentifikasi 64%, pendokumentasian yang benar 87%, dan laporan penting 76%. Kelengkapan pengisian resume medis berdasarkan elemen penilaian MIRM 15 SNARS Edisi1.1, kelengkapan pengisian elemen penilaian 1, 82%, elemen penilaian 2, 58%, elemen penilaian 3, 70%, elemen penilaian 4, 72%, elemen penilaian 5, 74% dan elemen penilaian 6 tidak dapat diterapkan karena ada item yang tidak tersedia. Penyebab ketidaklengkapan adalah ketidakpatuhan dokter, tidak adanya petugas assembling, kesibukan dokter, tidak adanya SPO resume medis, tidak adanya sanksi bagi dokter. Alternatif solusi adalah penambahan petugas assembling, pembuatan SPO resume medis dan disosialisasikan, desain ulang resume medis rawat inap, penerapan rewards dan punishment. Kesimpulan: Kelengkapan pengisian resume medis 70,25%. Ketercapaian EP MIRM 15 terhadap kelengkapan resume medis adalah lengkap 71,2% skor 5 dan terpenuhi sebagian. Faktor penyebab dilihat dari unsur man, method, dan motivation. Alternatif solusi adalah penambahan petugas assembling, pembuatan SPO resume medis dan disosialisasikan, desain ulang resume medis rawat inap dan penerapan rewards dan punishment.

Background: The incompleteness of filling out medical resume forms can have an impact on insurance claim services and can lead to a low assessment of the completeness of the medical record thereby reducing the quality of hospital services. From the results of preliminary studies, it is known that 29 forms of 87 inpatient medical resume forms at the RSI Sakinah Mojokerto are incomplete. Objective: To find out the percentage of completeness in filling in the form of medical resume for inpatient patients based on the MIRM 15 assessment element SNARS Edition 1.1 at RSI Sakinah Mojokerto and knowing the achievement of the MIRM 15 assessment element at the RSI Sakinah Mojokerto. Method: This type of descriptive qualitative research with a case study design. The study subjects numbered 5 people, consisting of 2 medical record officers, 2 nurses and 1 doctor. The object of research is 100 sheets of medical resume forms. Data collection techniques are observation studies, study documentation and interviews. The validity test of the data using source triangulation. Results: The results of the analysis of completing medical resumes based on 54% patient identification review, 64% authentication review, 87% correct documentation review, and 76% important report review. Completeness of filling medical resumes based on MIRM 15 assessment element SNARS Edition 1.1, completeness of filling assessment element 1 82%, assessment element 2 58%, assessment element 3 70%, assessment element 4 72%, assessment element 5 74%, and assessment element 6 cannot be applied because there are items that are not available. The causes of incompleteness are doctors non-compliance, absence of assembling officers, busyness of doctors, absence of SOP medical resumes, lack of sanction for doctors. Alternative solution are the addition of assembling officers, making SOP medical resume and socialized, redesigning inpatient medical resumes, applying rewards and punishment. Conclusion: Completeness of filling medical resumes 70,25%. Achievement of EP MIRM 15 on completeness of filling medical resumes is 71,2% complete score 5 and partially fulfilled. The causative factors is seen from the elements of man, method, and motivation. Alternative solutions are the addition of assembling officers, making SOP medical resume and socialization, redesigning inpatient medical resumes, and applying rewards and punishment.

Kata Kunci : Resume medis, akreditasi, analisis kelengkapan, SNARS