EVALUASI KELENGKAPAN BERKAS REKAM MEDIS RAWAT INAP BERDASARKAN STANDAR AKREDITASI DI KLINIK NOVA MEDIKA KLATEN

HARNUM MAWARTI, Marko Ferdian Salim, S.K.M., M.P.H

2021 | Tugas Akhir | D3 REKAM MEDIS DAN INFORMASI KESEHATAN

Latar Belakang: Klinik merupakan fasilitas pelayanan kesehatan yang menyelenggarakan pelayanan kesehatan perorangan yang menyediakan pelayanan rekam medis dasar dan atau spesifik. Akreditasi klinik dilakukan untuk menjamin kesehatan primer yang berkualitas, salah satu penilaian dalam akreditasi adalah pada berkas rekam medis. Pada saat observasi dilakukan pengambilan 10 berkas rekam medis rawat inap masih terdapat 80% formulir yang belum lengkap sedangkan berkas rekam merupakan dokumen penilaian akreditasi. Tujuan: Penelitian ini bertujuan untuk mengevaluasi tingkat kelengkapan berkas rekam medis rawat inap berdasarkan standar akreditasi kriteria 2.2.2 EP 1 dan 3.4.4 EP 1, serta melihat faktor penyebab ketidaklengkapan pengisian berkas rekam medis. Metode: Jenis penelitian adalah deskriptif kualitatif. Rencangan penelitian menggunakan studi kasus dan kuantitatif. Subjek yang dipakai adalah petugas kesehatan yang berkaitan dengan pengisian berkas rekam medis rawat inap. Objek peneliti adalah berkas rekam medis rawat inap pada kunjungan bulan Juli-September 2020. Keabsahan data yang digunakan triangulasi sumber dan teknik. Hasil: Hasil analisis kelengkapan item berkas rekam medis rawat inap sesuai dengan Standar Akreditasi Klinik. Hasil analisis presentase kelengkapan item rekam medis rawat inap berdasarkan kriteria 2.2.2 EP 1 sebesar 82% dan kriteria 3.4.4 EP 1 sebesar 63,7%. Faktor penyebab Man dan Method. Upaya mengatasinya dilakukan melengkapi berkas, melakukan analisis, penambahan petugas, meningkatkan komunikasi, sosialisasi SOP dan pentingnya kelengkapan. Kesimpulan: Kelengkapan item pada berkas rekam rawat inap sudah sesuai. Presentase kelengkapan pengisiannya adalah 82% dan 63,7%. Faktor penyebab ketidaklengkapan adalah Man dan Method Kata kunci: Akreditasi Klinik, analisis, faktor, upaya.

Background: Clinics as a form of health care facility provide individual health services and offer essential and specific medical record services. Accreditation for clinics is vital to ensure the realization of quality primary health, where one of the assessment categories in accreditation is the level of completeness of the medical record files that the clinic keeps. At the time of observation, ten inpatient medical record files were taken, 80% of the forms were incomplete, while the record files were accreditation assessment documents. Purpose: This study aims to evaluate the completeness of inpatient care medical record files based on the criteria for accreditation criteria 2.2.2 EP 1 and 3.4.4 EP 1 and look at the factors causing the incomplete filling of the medical record file. Methods: It was a qualitative descriptive study. The research design used case studies and quantitative methods. The subjects of this study were clinic staff tasked with filling out inpatient medical record files, while the object was inpatient medical record files on visits from July to September 2020. To ensure the validity of the data, the author applied the triangulation technique in this study. Results: The results of the analysis of the completeness of the inpatient medical record file items were per the Clinical Accreditation Standards. More specifically, the analysis results of the percentage of completeness of inpatient medical record items based on criteria 2.2.2 EP 1 were 82%, and criteria 3.4.4 EP 1 were 63.7%. Man and Method were observed to be the cause of the incomplete file. Various steps can be taken to overcome the incompleteness of the data, starting from completing the file before returning to the storage shelf, analyzing the completeness of the file, increasing the number of staff, strengthening communication between clinic staff, to socializing SOPs regarding the importance of completeness in filling out medical record files. Conclusion: The completeness of the items in the inpatient record file was under the Clinical Accreditation Standards, where the percentage of completeness is 82% and 63.7%, respectively. Factors causing incompleteness point out to Man and Method. Keywords: Clinical Accreditation, analysis, factors, efforts

Kata Kunci : Akreditasi Klinik, analisis, faktor, upaya.