Telaah rekam medis sebelum dan sesudah pelatihan dalam peningkatan mutu rekam medis pendidikan dokter spesialis anak di IRNA II RSUP Dr. Sardjito Yogyakarta :: Suatu penelitian eksperimen semu
MELIALA, Andreasta, dr. Sunartini, SpAK.,PhD
2001 | Tesis | S2 Ilmu Kesehatan MasyarakatKelengkapan rekam medis dan ketepatan waktu pengembaliannya masi h menjadi persoalan dimana-mana. Tidak hanya di negara berkembang, namun di negara majupun keadaan ini masih sering dijumpai. Fenomena diatas dapat dilihat melalui kinerja rekam medis di beberapa rumahsakit. Rekam medis merupakan catatan penting kegiatan pelayanan di rumah sakit. Oleh sebab itu, kelengkapannya dan ketepatan waktu pengembaliannya hams dijaga dengan baik. Diperlukan suatu audit rekam medis untuk menilai kelengkapan rekam medis tersebut, agar dapat berfungsi dengan sempurna. RSUP DR. Sardjito yang merupakan rumahsakit pendidikan mempunyai tanggung jawab yang cukup besar dalam mengatasi masalah dalam pengelolaan remkam medis. Peran dari para klinisi yang bekerja di rumahsakit sangat menentukan kelengkapan pengisan rekam medis dan ketepatan waktu pengembaliannya. Untuk itu perlu dilakukan penyegaran kembali kepada para klinisi mengenai arti penting rekam medis Tujuan dari penelitian ini adalah untuk menilai kelengkapan pengisian rekam medis yang dilakukan sebelum dan sesudah diadakan program pelatihan. Penelitian ini dilakukan di IRNA I1 RSUP DR. Sardjito Yogyakarta. Rancangan penelitian ini adalah pre eksperimen dengan penilaian sebelum dan sesudah perlakuan, tanpa kelompok pembanding. Peserta pelatihan, yang menjadi subyek dalam penelitian ini, adalah dokter residen yang bertugas di bangsal IRNA II, yang bertanggungjawab terhadap pengisian rekam medis pasien bangsal. Data penelitian didapatkan dari penilaian terhadap kelengkapan rekam medis pasien IRNA I1 yang dirawat 1 bulan sebelumdan sesudah pelatihan. Hasil dari penelitian ini menunjukkan , dari 30 seksi dalam 92 pasangan rekam medis, didapatkan hanya 4 seksi yang mengalami penuruna setelah pelatihan, sedangkan sisanya menunjukkan peningkatan. Secara statistik ditemukan perbedaan yang bermakna dengan t=3,66 pada p=O,OOl, dari rekam medis sebelum pelatihan dibanding rekam medis sesudah pelatihan. Namun demikian, target dari pelatihan ini, yaitu ketepatan waktu pengembalian dan pengisian kode ICD-X hasilnya masih memprihatinkan
To date, the completeness of medical record is still the main problem in the hospital information management. The core of the health information system in the hospital lies in the medical record, hch contain all the data concerning diseases and practices. Medical record completion shows the quality of medical record itself and also the quality of services given, in wider scope. Then question arise whether the medical records contain all the data needed in the reliable, complete and timely manners while meeting standards for audit and confidentiality. Therefore it's important to make a review on the completeness of the medical record and make a tial to enhance the quality of the medical record in the teaching hospital. Sardjito Hospital, as a teaching hospital take a huge responsibility in producing a professional clinicians, medicinal and administratively. The objective of this study is to identify the completeness of medical record, and to analyze the differences on the completeness of medm1 record before and after training programme. The location framed in the Paediatric ward inside the Sardjito Teachng Hospital Yogyakarta. The pre experiment study, quasy experiment , design was adopted in this study, an after and before study without control groups. The result of examination on medical record before the study became the base line data, and the result after training was the next data to compare with the one on the previous. Training programme as the predictor variable will be held by a professional and well-experienced trainer to influence the completeness of medical record as the criterion variable, which are represented on the assessment by the residences as a trainee, who have responsibility in the medical record of Paediatric inpatient ward. A statistical methode is used to analyze the scientific diffrences quantiatively and supported by the qualitative data that collected before and after training. Result: in 30 section of medical record, it is found that 4 of them decreased after training were implemented. But rest, increasing significantly. Statistically, training program influenced the completeness of medical record after training program, compared to medical record full-filled before training programm, at t-value: 3,66 on 0,001 2-tail significancy. Though, the main target on the training, ICD-X code and on time returning, is still poor and far from international standard. Conclusion: The differences between the 2 group of data shown significant, although practically this result may be under standard of optimum condition Recommendation: to improve the quality of further training program, it is suggested to merge all type of intervention that have been made in certain hospital, that also had been tested in MMR Institution.
Kata Kunci : Manajemen Rumah Sakit,Pendidikan Dokter Spesialis Anak,Rekam Medis, completeness of medical record, training programme
