Literature Review : Sistem Pelepasan Informasi Medis Di Rumah Sakit

VIA ANGRAINI, Marko Ferdian Salim, S.K.M., M.P.H

2021 | Tugas Akhir | D3 REKAM MEDIS DAN INFORMASI KESEHATAN

Latar Belakang: Pelepasan informasi medis di rumah sakit harus mengacu pada prosedur yang berlaku dan adanya surat kuasa atau persetujuan tertulis pasien agar tidak merugikan hak privasi pasien. Penelitian literature review terkait sistem pelepasan informasi medis di RS perlu dilakukan karena telah banyak penelitian lapangan terkait topik ini, namun masih minimnya penelitian yang menggunakan metode literature review dengan topik sistem pelepasan informasi medis di rumah sakit. Tujuan: Mereview literatur terkait pelepasan informasi medis di rumah sakit. Metode: Penelitian ini menggunakan desain penelitian literature review dengan pendekatan narrative review. Pencarian literatur menggunakan strategi dengan model PICO dengan rekam medis sebagai population dan pelepasan informasi medis sebagai outcome. Database pencarian literatur yang digunakan yaitu PubMed, Google Scholar, Cochrane Library, dan ScienceDirect. Adapun kriteria inklusi terdiri dari tahun terbit literatur adalah 2015-2021, literatur terkait pelepasan informasi medis, dan menggunakan bahasa indonesia atau inggris. Serta kriteria ekslusi terdiri dari literatur tidak full text, dan topik terkait tinjauan hukum pembukaan rekam medis. Hasil: Pencarian literatur menemukan 11 literatur yang memenuhi kriteria terkait pelepasan informasi medis di rumah sakit yang mencakup prosedur, persyaratan dan pihak yang terlibat. Komponen prosedur pelepasan informasi medis di rumah sakit yang paling banyak digunakan adalah SPO yang mengatur pengurusan pelepasan informasi rekam medis kepada pihak ketiga baik asuransi, pendidikan, dan kepolisian/pengadilan dengan persentase sebesar 73% dari 11 literatur yang diteliti. Kemudian untuk persyaratan dalam pelepasan informasi medis kepada pihak ketiga baik pihak asuransi, peneliti/pendidikan, pengadilan/kepolisian, dan pasien/keluarga pasien yang paling banyak diminta adalah surat kuasa atau persetujuan tertulis dari pasien dengan persentase sekitar 75% dari total 8 literatur yang diteliti. Serta pihak yang paling sering terlibat dalam proses pelepasan informasi medis pasien di rumah sakit yaitu perekam medis (89%) dan dokter (78%) dari total 9 literatur yang diteliti. Kesimpulan: Peneliti berharap semoga penelitian ini dapat menjadi acuan peneliti lain untuk mengembangkan lagi penelitian menggunakan metode systematic review terkait pelepasan informasi medis di rumah sakit.

Background: The release of medical information in a hospital must refer to the applicable procedures and the existence of a power of attorney or written consent of the patient so as not to harm the patient's right to privacy. Literature review research related to the medical information release system in hospitals needs to be done because there have been many field studies related to this topic, but there is still a lack of research using the literature review method with the topic of medical information release systems in hospitals. Objective: Reviewing the literature regarding the release of medical information in hospitals. Methods: This study uses a literature review research design with a narrative review approach. The literature search used a strategy with the PICO model with medical records as the population and the release of medical information as the outcome. The literature search databases used are PubMed, Google Scholar, Cochrane Library, and ScienceDirect. The inclusion criteria consist of the year of publication of the literature is 2015-2021, literature related to the release of medical information, and using Indonesian or English. And the exclusion criteria consisted of not full text literature, and topics related to the legal review of the opening of medical records. Results: The literature search found 11 literatures that met the criteria regarding the release of medical information in hospitals which included procedures, requirements and parties involved. The component of the procedure for releasing medical information in hospitals that is most widely used is the SPO which regulates the management of the release of medical record information to third parties, both insurance, education, and the police/court with a percentage of 73% of the 11 literatures studied. Then for the requirements for releasing medical information to third parties, including insurance, researchers/education, courts/police, and patients/patient families, the most requested power of attorney or written consent from patients with a percentage of about 75% of the total 8 literature studied. And the parties most often involved in the process of releasing medical information from patients in hospitals are medical recorders (89%) and doctors (78%) from a total of 9 literatures studied. Conclusion: Researchers hope that this research can be a reference for other researchers to develop further research using a systematic review method related to the release of medical information in hospitals.

Kata Kunci : Sistem Pelepasan Informasi Medis, Rekam Medis, Rumah Sakit