Perancangan Prototipe Aplikasi Analisis Kelengkapan Pengisian Rekam Medis Elektronik Rawat Inap di Rumah Sakit Syarif Hidayatullah

Arina Salsabila, Angga Eko Pramono, S.K.M., M.P.H.

2025 | Tugas Akhir | D4 MANAJEMEN INFORMASI KESEHATAN

Latar Belakang: Rumah sakit mempunyai kewajiban menyelenggarakan rekam medis elektronik dalam upaya pelayanan kesehatan sesuai dengan amanah pada PMK No. 24 tahun 2022 tentang Rekam Medis. Peran penting rekam medis yaitu sebagai salah satu pengukuran indikator mutu pelayanan kesehatan di rumah sakit. Indikator yang diukur dalam rekam medis yaitu kelengkapan formulir rekam medis, pemenuhan persyaratan hukum, tepat waktu, dan keakuratan. Rumah Sakit Syarif Hidayatullah dalam penyelenggaraan rekam medis pasien rawat inap per tahun 2022 masih menggunakan rekam medis manual, oleh karena itu dalam rangka mempersiapkan rekam medis elektronik rawat inap maka perlu dilakukan perancangan instrumen aplikasi yang dapat menganalisis kelengkapan pengisian catatan medis pasien rawat inap sebagai upaya kendali mutu pada rekam medis elektronik.

Tujuan: Merancang instrumen aplikasi analisis kelengkapan catatan medis elektronik rawat inap di Rumah Sakit Syarif Hidayatullah.

Metode: Perancangan menggunakan konsep Systems Development Life Cycle (SDLC). Subjek penelitian yaitu petugas rekam medis, kepala instalasi rawat inap, kepala komite mutu, dan ketua tim IT di RS Syarif Hidayatullah. Teknik pengumpulan data dilakukan dengan observasi lapangan, studi dokumentasi, dan wawancara narasumber. Teknik analisis data menggunakan triangulasi sumber dan metode.Teknik pengujian dan evaluasi sistem menggunakan Focus Group Discussion (FGD).

Hasil: Perancangan prototipe aplikasi analisis kelengkapan pengisian catatan rekam medis elektronik telah sesuai dengan analisis kebutuhan yaitu dapat digunakan untuk menganalisis dan menampilkan hasil nilai dan persentase terhadap kelengkapan rekam medis elektronik. Hasil evaluasi sistem oleh para responden dapat diterima, disetujui, disepakati dapat mewakili nilai mutu isi rekam medis elektronik, dan memiliki potensi untuk diterapkan di lingkungan rumah sakit.

Kesimpulan: Hasil perancangan prototipe aplikasi analisis rekam medis elektronik berdasarkan hasil evaluasi oleh pengguna telah sesuai dengan kebutuhan data dan dapat menghasilkan luaran laporan rekapitulasi yang dapat menunjukkan nilai mutu isi rekam medis elektronik.

Background: A hospital has an obligation to organize an electronic medical record in order to support health service efforts as PMK No. 24 in 2022 about Medical Records. The important role of medical records is as to measurement of quality indicators of health service in a hospital. The indicator that would be measured in medical records is the completeness of medical record forms, have fulfilled legal requirements, on time, and the accuracy. Syarif Hidayatullah Hospital in order to organize medical records for inpatients in 2022 still used manual medical records, because of that, in order to preparing medical records for inpatients then it is needed to make an application instrument planning that could analyze the completeness of inpatient medical records as the control of the quality of electronic medical records.

Objective: Designing an application instrument of the completeness of the electronic inpatient medical records in Syarif Hidayatullah Hospital.

Methods: The concept of the design was used as a Systems Development Life Cycle (SDLC). The subjects of this research were the medical records staff, the leader of inpatient unit, the quality comitee staff, dan the leader of technology information in Syarif Hidayatullah Hospital. The technique of analysis data used data and method trangulation. The technique of collecting data was done by field observation, study documentation, and interview. The technique of testing and evaluation system used by Focus Group Discussion (FGD).

Results: The prototype application design for analyzing the completeness of electronic medical records aligned with the needs analysis and could be used to assess and display the results and percentage of completeness of the electronic medical records. The results of the system evaluation by users were acceptable, approved, and agreed upon, indicating that the application could represent the quality of electronic medical record content and had the potential to be implemented in hospitals.

Conclusion: The results of the prototype application for analyzing electronic medical records, based on user evaluations, were appropriate for the data requirements and could generate a report as output that reflects the quality of the electronic medical record content.

Kata Kunci : KLPCM, SDLC, indikator mutu, rekam medis elektronik, perancangan aplikasi.