ANALISIS KETIDAKLENGKAPAN PENGISIAN REKAM MEDIS PASIEN RAWAT INAP DI RSUD KAYEN PATI

ALBIYA YAUMI T R, Dina Fitriana Rosyada, M.KL.

2021 | Tugas Akhir | D3 REKAM MEDIS DAN INFORMASI KESEHATAN

Latar belakang: Rekam medis merupakan berkas berisi identitas pasien, pemeriksaan, pengobatan, tindakan, dan pelayanan lain yang diberikan kepada pasien. Rekam medis sebaiknya dibuat secara lengkap agar pelayanan kesehatan yang diberikan berkesinambungan. Berdasarkan hasil studi dokumentasi terhadap 20 berkas rekam medis pasien rawat inap di RSUD Kayen Pati diperoleh persentase ketidaklengkapan komponen identifikasi sebanyak 29%, laporan penting sebanyak 43%, autentikasi sebanyak 23%, dan praktik pencatatan sebanyak 30%. Hasil tersebut menunjukkan bahwa ketidaklengkapan pengisian rekam medis pasien rawat inap masih tinggi. Tujuan: Menganalisis ketidaklengkapan pengisian rekam medis pasien rawat inap di RSUD Kayen Metode: Penelitian dilaksanakan di RSUD Kayen, beralamat di Jl. Rumah Sakit No.1, Kayen, Pati, Jawa Tengah pada Bulan Oktober-November 2020. Jenis penelitian yaitu deskriptif kualitatif dengan rancangan studi kasus. Teknik pengumpulan data melalui wawancara dan studi dokumentasi. Subjek penelitian meliputi seorang petugas assembling, empat orang perawat, dua orang dokter, dan Kepala Instalasi Rekam Medis. Objek penelitian yaitu 85 rekam medis pasien rawat inap triwulan ketiga Tahun 2020 serta SOP tentang pencatatan dan analisis kelengkapan rekam medis rawat inap. Hasil: Berdasarkan empat komponen analisis kuantitatif, persentase ketidaklengkapan tertinggi terdapat pada komponen laporan penting. Faktor penyebab ketidaklengkapan meliputi unsur man, material, dan method. Alternatif solusi yang diberikan yaitu penerapan reward dan punishment, penggalangan komitmen, penyederhanaan formulir, evaluasi dan tindak lanjut, serta penerapan RME. Kesimpulan: Solusi yang dapat diterapkan dalam waktu dekat yaitu pemberlakuan reward dan punishment serta penggalangan komitmen. Sebaiknya petugas melakukan sosialisasi dan menyiapkan rencana pelaksanaan tindakan. Kata Kunci: pemecahan masalah, ketidaklengkapan rekam medis, rekam medis pasien rawat inap.

Background: Medical records are files containing patient identities, examinations, treatments, actions, and other services provided to patients. Medical records should be made in full so that the health services provided are sustainable. Based on a documentation study of 20 files of inpatients medical record at RSUD Kayen Pati, the percentage of incomplete identification components was 29%, necessary reports 43%, authentication 23%, and recording practice 30%. These results indicate that the incompleteness of filling in the medical records of inpatients is still high. Objective: To analyze the incompleteness of filling in the medical records of inpatients at Kayen Pati Hospital. Methods: The study was conducted at Kayen Hospital, having its address at Jl. Hospital No.1, Kayen, Pati, Central Java in October-November 2020. This type of research is descriptive qualitative with a case study design. Data collection techniques through interviews and documentation study. The research subjects included an assembling officer, four nurses, two doctors, and the Head of the Medical Record. The object of research is 85 inpatients medical records in the third quarter of 2020 and SOP on recording and analyzing the completeness of inpatient medical records. Results: Based on the four components of the quantitative analysis, the highest percentage of incompleteness was found in the necessary report. Factors causing incompleteness including man, material, and method. Alternative solutions provided are the application of rewards and punishments, raising commitment, simplifying forms, evaluation and follow-up, and implementing RME. Conclusion: The solution that can be applied in the near future is the application of rewards and punishments and building commitment. It is advisable for the officers to socialize and prepare an action plan. Keywords: problem solving, incomplete medical records, inpatient medical records.

Kata Kunci : pemecahan masalah, ketidaklengkapan rekam medis, rekam medis pasien rawat inap.