ANALISIS KESIAPAN PENGGUNAAN REKAM MEDIS ELEKTRONIK DI INSTALASI RAWAT JALAN RSUD BAHTERAMAS PROVINSI SULAWESI TENGGARA

Devi Emrianti. R, Adhistya Erna Permanasari, ST.,MT.,Ph.D ; Dr. dr. Guardian Yoki Sanjaya, MHlthInfo

2023 | Tesis | MAGISTER KEBIJAKAN DAN MANAJEMEN KESEHATAN

Latar Belakang : Rekam medis merupakan berkas yang berisikan catatan dan dokumen tentang identitas pasien, pemeriksaan, pengobatan serta tindakan dan pelayanan lain kepada pasien selama mendapatkan perawatan di penyedia layanan kesehatan baik rawat jalan maupun rawat inap. Melalui Peraturan Menteri Kesehatan No. 24 tahun 2022 dimana semua fasilitas pelayanan kesehatan (Fasyankes) diwajibkan menjalankan sistem pencatatan riwayat medis pasien secara elektronik. RSUD Bahteramas saat ini sedang dalam tahap penerapan rekam medis elektronik di Instalasi Rawat Jalan. Tingkat kesiapan suatu fasilitas pelayanan Kesehatan dalam implementasi rekam medis elektronik perlu dilakukan agar bisa membantu dalam mengoptimalisasi penerapan rekam medis elektronik. pengukuran kesiapan penerapan rekam medis elektronik di RSUD Bahteramas menggunakan Electronic Health Record (EHR) Assessment and Readiness Starter Assessment oleh Doctor’s Office Quality-Information Technology (DOQ IT)

Tujuan : Menganalisis kesiapan RSUD Bahteramas dalam menerapkan rekam medis elektronik di instalasi rawat jalan

Metode Penelitian : Jenis penelitian yang digunakan dalam penelitian ini adalah penelitian deskriptif dengan pendekatan kualitatif. pengumpulan data dilakukan dengan wawancara mendalam dan observasi mengukur tingkat kesiapan penerapan rekam medis elektronik di instalasi rawat jalan menggunakan EHR Assessment and Readiness Starter Assessment oleh Doctor’s Office Quality-Information Technology (DOQ IT). Informan dalam penelitian ini berjumlah 11 orang. 

Hasil : hasil analisis dalam penerapan rekam medis elektronik di RSUD Bahteramas dinilai cukup siap, dilihat dari beberapa area penilaian diantaranya sumber daya manusia berada pada range II, budaya kerja organisasi berada pada range III, tata Kelola kepemimpinan berada pada range III dan infrastruktur berada pada range III. Akan tetapi masih diperlukan perhatian seperti penambahan komputer dokter, perbaikan jaringan serta keterlibatan pasien dalam mendukung penerapan rekam medis elektronik.

Kesimpulan : Secara keseluruhan kesiapan penerapan rekam medis elektronik di RSUD Bahteramas berada pada range II dalam interpretasinya menunjukkan bahwa, ada kemampuan yang baik di beberapa komponen kesiapan, namun ada pula beberapa kelemahan di beberapa komponen, sehingga diperlukan identifikasi dan antisipasi lebih lanjut pada komponen yang lemah, agar implementasi bisa tetap berjalan baik

Background: Medical record is a file that contains notes and documents regarding patient identity, examination, treatment and other actions and services for patients while receiving treatment at health service providers both outpatient and inpatient. Through Regulation of the Minister of Health no. 24 of 2022 where all health service facilities are required to run an electronic patient medical history recording system. Bahteramas Hospital is currently in the stage of implementing electronic medical records in the Outpatient Installation. The level of readiness of a health service facility in implementing electronic medical records needs to be done so that it can assist in optimizing the implementation of electronic medical records.

Objective :Analyzing the readiness of Bahteramas Hospital in implementing electronic medical records in outpatient installations

Research methods :The type of research used in this research is descriptive research with a qualitative approach. data collection was carried out by in-depth interviews and observations measuring the level of readiness for implementing electronic medical records in outpatient installations using the EHR Assessment and Readiness Starter Assessment by the Doctor's Office Quality-Information Technology (DOQ IT). Informants in this study amounted to 11 people.

Results :the results of the analysis in the application of electronic medical records at Bahteramas Hospital were considered quite ready, seen from several assessment areas including human resources in range II, organizational work culture in range III, leadership governance in range III and infrastructure in range III. However, attention is still needed, such as adding doctors' computers, network improvements and patient involvement in supporting the implementation of electronic medical records.

Conclusion : Overall, the readiness to implement electronic medical records at Bahteramas Hospital is in range II in its interpretationshows that, there is good capability in several components of readiness, but there are also some weaknesses in several components, so further identification and anticipation of weak components is needed, so that implementation can continue to run well.

Kata Kunci : Rekam Medis Elektronik, DOQ-IT, Kesiapan