PERANCANGAN FORMULIR DAN SPO PENGISIAN REKAM MEDIS RAWAT INAP DI LABORATORIUM DLIKES SV UGM

ALBERT ARDIKA TAMA, Nuryati,S.Far.,M.P.H.

2021 | Tugas Akhir | D3 REKAM MEDIS DAN INFORMASI KESEHATAN

Latar Belakang: Rekam medis digunakan sebagai media pembelajaran, dalam menunjang pembelajaran rekam medis, setiap perguruan tinggi wajib memiliki kurang lebih tujuh laboratorium, salah satu contohnya adalah laboratorium rekam medis manual yang berada di Prodi RMIK SV UGM. Laboratorium rekam medis manual ini digunakan untuk beberapa praktik salah satu contohnya desain formulir, namun untuk praktik desain formulir laboratorium masih dianggap kurang layak karena hanya terdapat beberapa formulir rekam medis saja dan formulir tersebut sudah tidak sesuai dengan aspek desain formulir, serta tidak memiliki SPO pengisian formulir. Sehinga perlu perancangan formulir rekam medis rawat inap yang kurang lebih dapat memberi gambaran formulir yang ada di rumah sakit beserta SPO pengisian formulir. Tujuan: Merancang dan merancang ulang formulir serta SPO pengisian rekam medis rawat inap di laboratorium rekam medis manual SV UGM. Metode: Jenis penelitian perancangan dengan pendekatan kualitatif. Perancangan ini mengacu pada RCH Forms Committee tahun 2006. Analisis kebutuhan formulir berdasarkan elemen penilaian pada SNARS edisi 1 tahun 2017 sedangkan analisis kebutuhan item data formulir menggunakan wawancara dengan informan dan studi banding formulir melalui Tugas Akhir yang sudah ada dan dengan formulir yang ada di rumah sakit. Hasil: Hasil akhir berupa empat belas formulir dan SPO pengisian rekam medis rawat inap dimana empat diantaranya adalah hasil perancangan ulang dan sepuluh diantaranya adalah perancangan baru. Empat formulir perancangan ulang adalah formulir ringkasan masuk dan keluar, formulir resume medis, formulir informed consent, dan formulir pernyataan penolakan. Sedangkan perancangan baru berupa formulir general consent, formulir asesmen awal medis, formulir asesmen awal keperawatan, formulir asesmen prabedah, formulir rekonsiliasi obat, formulir CPPT, formulir penempelan hasil laboratorium, formulir laporan operasi, formulir transfer pasien, formulir rujukan. Kesimpulan: Formulir yang dirancang berjumlah empat belas formulir dimana empat diantaranya adalah perancangan ulang dan sepuluh formulir lainnya adalah perancangan baru, selain itu juga dirancang SPO pengisian formulir.

Background: Medical records are used as a learning medium. In supporting medical record learning, each university required to have approximately seven laboratories, including manual medical record laboratory located in the RMIK SV UGM study program. Manual medical record laboratories are used for several practices, for example is form design but for the practice of laboratory form design it is still considered inadequate because there are only a few medical record forms and the form is not in accordance with the form design aspect, and does not have an SOP for filling out the form. So, it is necessary to design an inpatient medical record form that more or less can provide an overview of the forms in the hospital along with the SOP for filling out the form. Purpose: Designing and redesigning forms and SOP filling out inpatient medical records in the SV UGM manual medical record laboratory. Method: This type of research design with a qualitative approach. This design refers to the RCH Forms Committee of 2006. Analysis of the needs of the form is based on the assessment elements in SNARS 1st edition of 2017, while the needs analysis of the form data items uses interviews with informants and comparative studies of forms through existing final projects and with existing forms in the hospital. Results: The final results are fourteen forms and SOP for filling out inpatient medical records where four of them are the result of redesign and ten of them are new designs. The four redesign forms were the entry and exit summary form, the medical resume form, the informed consent form, and the refusal form. While the new design is in the form of general consent form, initial medical assessment form, initial nursing assessment form, preoperative assessment form, drug reconciliation form, CPPT form, laboratory results attachment form, operation report form, patient transfer form, referral form. Conclusion: There are fourteen forms designed, four of which are redesigns and ten other forms are new designs. Besides that, SOP for filling out forms are also designed.

Kata Kunci : Rancangan, Formulir, SPO, Rekam Medis, Rawat Inap, Laboratorium.