Perancangan Aplikasi Analisis Kelengkapan Rekam Medis Konvensional di RSUD Tidar Kota Magelang

Widya Ajeng Pangestika, Angga Eko Pramono, SKM., MPH.

2024 | Tugas Akhir | D4 MANAJEMEN INFORMASI KESEHATAN

Latar belakang: Kualitas kelengkapan rekam medis merupakan salah satu aspek yang harus tercapai dalam memenuhi kualitas mutu pelayanan. Mutu hasil pekerjaan seorang profesi pemberi asuhan dapat dinilai dari bagaimana kualitas pengisian berkas rekam medis yang menjadi kewajibannya. Sistem analisis kelengkapan perlu diperhatikan untuk mendukung peningkatan kelengkapan. Sedangkan masalah di lokasi penelitian adalah analisa kelengkapan yang belum terintegrasi dengan SIMRS sehingga memberi beban lebih pada petugas dalam menyusun pelaporan. Selain itu, kegiatan analisis kelengkapan tidak dapat dilakukan dalam waktu dekat setelah pasien pulang.

Tujuan : Merancang aplikasi yang terintegrasi dengan SIMRS untuk analisis kelengkapan dan menghasilkan output rekapitulasi sebagai pelaporan tingkat kelengkapan pengisian rekam medis.

Metode : Penelitian menggunakan metode prototyping dengan 5 tahapan yang meliputi identification user need, concept design, create prototype, prototype test, and implementation and evaluation dengan diagram Unified Modeling Language (UML). Subjek penelitian ini adalah orang atau instansi yang menjadi sumber data atau informasi pada ruang lingkup analisis kelengkapan pengisian rekam medis di RSUD Tidar. Sedangkan metode pengumpulan data dilakukan dengan wawancara, observasi, FGD, studi dokumentasi dan kuesioner.

Hasil : Penelitian perancangan menghasilkan aplikasi analisis kelengkapan rekam medis sesuai analisis kebutuhan. Hasil uji coba dinilai menggunakan kuesioner PSSUQ dari segi faktor System Usefullness, Information Quality, Interface Quality, dan Overall Satification yang diberikan skor 3,042; 2,88; 2,83; dan 2,875. Data tersebut diperoleh dari pengisian kuesioner oleh empat orang petugas analisis kelengkapan

Kesimpulan : Berdasarkan hasil uji coba dengan penilaian melalui kuesioner PSSUQ prototipe dapat diterima oleh pengguna. Sebagai saran, SIMRS diharapkan dapat mengadopsi hasil rancangan ini. Selain itu juga perlu dilakukan sosialisasi tentang kegiatan analisis kelengkapan rekam medis dan laporan yang dihasilkan

Background: The complete quality of medical records is one of the aspects that must be achieved in fulfilling the quality of service. The quality of the work of a professional care provider can be assessed by the quality of filling in the medical record files, which are their obligations. The completeness analysis system needs to be considered to improve completeness. Meanwhile, the problem at the research location is that the completeness analysis needs to be integrated with SIMRS, thus placing more burden on officers in compiling reports. In addition, completeness analysis activities cannot be done immediately after the patient returns.

Objective: Design an application that is integrated with SIMRS for completeness analysis and produces recapitulation output as reporting the level of completeness of filling in medical records.

Method: The research uses the prototyping method with 5 stages which include identification user need, concept design, create prototype, prototype test, and implementation and evaluation with Unified Modeling Language (UML) diagrams. The subjects of this research are people or agencies who are sources of data or information in the scope of analysis of the completeness of filling out medical records at Tidar Regional Hospital. Meanwhile, data collection methods were carried out using interviews, observation, FGD, documentation studies and questionnaires.

Result: The design research produced a prototype application for analysing the completeness of medical records according to the needs analysis. The trial results were assessed using the PSSUQ questionnaire in terms of the System Usefulness, Information Quality, Interface Quality and Overall Satisfication factors which were given a score of 3,042; 2,88; 2,83; dan 2,875. This data was obtained from filling out a questionnaire by two completeness analysis officers.

Conclusion: Based on the results of trials with assessment via the PSSUQ questionnaire, the prototype can be accepted by users. As a suggestion, it is hoped that SIMRS can adopt the results of this design. It is also necessary to provide information regarding activities to analyse the completeness of medical records and the reports produced.

Kata Kunci : Analisis Kelengkapan Rekam Medis, Prototyping, Unified Modeling Language