LITERATURE REVIEW: ANALISIS KELENGKAPAN PENGISIAN BERKAS REKAM MEDIS PASIEN RAWAT INAP DI RUMAH SAKIT INDONESIA

RINA WIDYASTUTI, Nuryati, S.Far., M.P.H

2021 | Tugas Akhir | D3 REKAM MEDIS DAN INFORMASI KESEHATAN

Latar Belakang: Pengisian rekam medis wajib dilakukan secara komprehensif, lengkap, dan tepat waktu. Rekam medis yang lengkap dapat menunjang mutu pelayanan. Namun, ketercapaian kelengkapan rekam medis masih cukup rendah. Terbukti pada penelitian Kurnianingrum (2015) ditemukan tingkat ketidaklengkapan identifikasi 20%, pelaporan 53%, pencatatan 56%, dan autentifikasi 51%. Tujuan: Menganalisis kelengkapan, mengidentifikasi penyebab, dan mengkaji upaya menanggulangi ketidaklengkapan BRM. Metode: Literature review dengan database Google Scholar dan Garuda. Kata kuncinya pada Google Scholar "Analisis OR Analysis AND Kelengkapan OR Completeness AND Rekam Medis OR Medical Records", sedangkan pada Garuda "Kelengkapan Rekam Medis Rawat Inap" dan didapatkan 546 artikel. Dilakukan Skrining duplikasi, judul, abstrak, dan full text sehingga didapatkan 17 artikel. Hasil: Rata-rata ketercapaiannya yaitu identifikasi 73,38%; laporan penting 78,30%; autentifikasi 78,93%; dan pendokumentasian 68,06%. Hal tersebut disebabkan diantaranya dari aspek man yaitu kedisiplinan dan keterbatasan waktu, kurangnya kesadaran, pengetahuan, dan ketelitian petugas, machine yaitu belum adanya SPO, method yaitu kurangnya sosialisasi, material yaitu banyaknya formulir, dan money yaitu keterbatasan dana. Upaya yang dilakukan yaitu dari man dengan adanya PMIK, machine yaitu memberikan sanksi/teguran, method yaitu melakukan sosialisasi, material yaitu mengadakan SPO. Kesimpulan: Capaian kelengkapan rekam medis rata-rata pada kategori cukup. Faktor penyebab ketidaklengkapannya meliputi aspek man, method, material, machine, dan money. Namun, beberapa rumah sakit sudah melakukan upaya untuk meminimalisir ketidaklengkapan rekam medis meliputi man, method, material, dan machine. Kata kunci: Analisis, kelengkapan rekam medis, rawat inap

Background: Medical records have to be filled comprehensively, completely, and on time. The completeness of medical records can increase quality of patient's services. However, completeness of inpatient medical records was quite low. It is proven that in Kurnianingrum (2015), obtained incompleteness identification 20%, reporting 53%, documentation 56%, and authentication 51%. Objective: Analyze completeness, identify the cause, and assess the efforts to overcome incompleteness Method: Literature review using Google Scholar and Garuda databases. The keywords used at Google Scholar "Analisis OR Analysis AND Kelengkapan OR Completeness AND Rekam Medis OR Medical Records", meanwhile at Garuda "Kelengkapan Rekam Medis Rawat Inap" and obtained 546 articles. From the obtained articles, the researchers screened duplication, titles, abstracts, and full text then obtained 17 articles. Result: The average achievement of each component is identification 73,38%; reporting 78,30%; authentication 78,93%; and documentation 68,06%. Causal factors from "man" were the lack of discipline, time constraints, lack of awareness and knowledge, "machine" was the absence of SOP, "method" was lack of socialization, "material" was many forms, "money" was limited funds. Efforts were made, form "man" was the presence of PMIK, "machine" was the presence of sanctions, "method" was socializing SPO, and "material" was made SPO. Conclusion: The average medical records completeness is in moderate range. The incompleteness influenced several factors including man, method, material, machine, and money. However, several hospitals have made efforts to minimize the incompleteness medical records including man, method, material, and machine. Keywords: Analysis, completeness of medical records, inpatient

Kata Kunci : Analisis, kelengkapan rekam medis, rawat inap, Analysis, completeness of medical records, inpatient