EVALUASI IMPLEMENTASI REKAM MEDIS DI INSTALASI RAWAT INAP RUMAH SAKIT PKU MUHAMMADIYAH YOGYAKARTA

Muhammad Agus Mikrajab, dr. Lutfan Lazuardi, M.Kes., Ph.D.

2011 | Tesis | S2 Ilmu Kesehatan Masyarakat

Latar Belakang: Rekam medis telah dilaksanakan RS PKU Muhammadiyah, Yogyakarta sejak tahun 2009. Namun, dalam pelaksanaannya mengalami berbagai kendala, terutama resistensi pengguna, kompleksitas konten teknologi, dan pengetahuan SDM RS terhadap implementasi rekam medis, Penelitian ini mengevaluasi implementasi rekam medis dengan menggunakan kerangka teori, yaitu kerangka HOT fit yang dikembangkan oleh Yusof et al. (2008) yang melihat dari dimensi Manusia, Organisasi, dan Teknologi. Tujuan Penelitian: Mengidentifikasi karakteristik rekam medis, mengidentifikasi manfaat dan hambatan dalam implementasi rekam medis, dan mengevaluasi implementasi rekam medis menurut dimensi teknologi, SDM RS, dan organisasi di instalasi rawat inap rumah sakit PKU Muhammadiyah Yogyakarta. Metode Penelitian: Penelitian Studi Kasus dengan metode campuran (mixed methods). Penelitian dilaksanakan di instalasi rawat inap RS PKU Muhammadiyah Yogyakarta. Subyek penelitian ini sebanyak 21 orang dengan rincian 2 dokter spesialis, 5 perawat, 5 bidan, manajer rekam medis, 3 perekam medis, 4 staf TI/EDP dan 1 staf jaminan mutu. Hasil: Sebanyak 8 responden (38,10%) menyatakan konten rekam medis tidak Sesuai dengan kebutuhan. 10 responden (47,62%) menyatakan SDM RS kurang mengetahui komponen, fungsi, sistem keamanan dan paperless office. 7 responden (33,33%) pengguna masih resisten terhadap sistem, serta 5 responden (23,81%) menyatakan pola kerja di RS tidak mendukung peningkatan kinerja dibidang teknologi informasi kesehatan. Kesimpulan: Semua klinisi belum menggunakan rekam medis dalam pelayanan kesehatan rawat inap terutama karena resistensi terhadap rekam medis, sehingga diperlukan kebijakan tertulis dan pelatihan bertahap dalam rangka meningkatkan pelayanan kesehatan di instalasi rawat inap.

Background: Medical Record has been implemented in Muhammadiyah Hospital since 2009. Although, its practice has faced several barriers mainly user resistance, complexity of technology contents, and knowledge of hospital human resources toward implementation of medical record. This study was to carried out evaluate the implementation of medical record according to HOT Fit framework by Yusof et al. (2008), the framework will be identified by technology, hospital human resources, and hospital organization of dimensions Objectives:,To identify the human resources characteristics that were used medical record, to identify benefit and barrier implementing medical record, and to evaluate implementation of medical record at inpatient department Muhammadiyah Hospital, Yogyakarta. Method: This research was a case study with mixed methods approaches. The subjects of this research were 2 physician/specialists, 5 nurses, 4 midwives, medical record manager, 3 medical record staff, 4 IT staff, and 1 quality assurance staff. Results: The results indicated that there were eight (38,10%) respondents stated that medical record system contents were not fitness with end user needs. There were ten (47,62%) respondents stated that hospital human resources lack of knowledge about components, functions, security system and knowledge about the paperless office. Seven (33,33%) respondents still resistance with system, and there were five (23,81%) respondents stated that job manner in hospital didn’t support enhancing performance in health information technology. Conclusion: All clinicians were not yet adopted the medical record in healthcare because user resistance toward medical record. Hence, we need a health policy and training step by step in order to enhancing health care at inpatient Muhammadiyah Hospital, Yogyakarta.

Kata Kunci : evaluasi, implementasi, rekam medis, instalasi rawat inap kerangka HOT fit, rumah sakit.