PENDOKUMENTASIAN REKAM MEDIS STANDAR PP 2.3 AKREDITASI KARS 2012 DIAGNOSIS DIABETES MELITUS DI RSUD TIDAR KOTA MAGELANG

BRIAN APRIAMUDITA, SAVITRI CITRA BUDI, SKM., MPH

2015 | Tugas Akhir | D3 REKAM MEDIS SV

Latar Belakang : Rumah sakit adalah institusi pelayanan kesehatan yang menyelenggarakan pelayanan kesehatan perorangan secara paripurna yang menyediakan pelayanan rawat inap, rawat jalan, gawat darurat. Rumah sakit wajib membuat, melaksanakan, dan menjaga mutu pelayanan kesehatan di Rumah sakit sebagai acuan standar pelayanan terhadap pasien. Dalam upaya peningkatan mutu pelayanan, rumah sakit wajib melakukan akreditasi secara berkala minimal 3 (tiga) tahun sekali. Berdasarkan hasil studi pendahuluan melalui wawancara dengan kepala rekam medis, diketahui bahwa RSUD Tidar Kota Magelang dalam persiapan untuk melaksanakan akreditasi KARS 2012. Bab Pelayanan Pasien (PP) termasuk dalam kelompok mayor penilaian akreditasi dan unit rekam medisnya berfokus dalam perbaikan kelengkapan serta pendokumentasian rekam medis. Di RSUD Tidar Kota Magelang diagnosis diabetes melitus merupakan 10 besar penyakit rawat inap dan hasil studi pendahuluan persentase kelengkapan pendokumentasian tindakan adalah 68% dan hasil tindakan adalah 73%, padahal nilai kelulusan yang diperlukan adalah 80%. Tujuan : Penelitian ini bertujuan untuk mengetahui pelaksanaan pendokumentasian rekam medis berdasarkan standar PP 2.3 akreditasi KARS 2012 diagnosis diabetes melitus di RSUD Tidar Kota Magelang. Metode Penelitian : Jenis penelitian yang digunakan untuk penelitian ini adalah metode penelitian deskriptif dengan pendekatan kualitatif dan rancangan studi kasus. Sampel yang digunakan adalah 100 berkas rekam medis pasien diagnosis diabetes melitus. Teknik pengumpulan data dengan wawancara dan studi dokumentasi. Hasil : Pelaksanaan standar PP 2.3 akreditasi KARS 2012 telah dilaksanakan di RSUD Tidar Kota Magelang karena tindakan dan hasil tindakan telah di dokumentasi pada lembar yang telah disediakan. Dan berdasarkan studi dokumentasi 100 berkas rekam medis diperoleh angka keterisian tindakan terisi lengkap sebanyak 77%, terisi tidak lengkap 3%, dan tidak terisi adalah 20%. Sedangkan angka keterisian hasil tindakan adalah terisi lengkap 78%, terisi tidak lengkap 17%, dan tidak terisi 5%. Ketercapaian standar PP 2.3 akreditasi KARS 2012 di RSUD Tidar Kota Magelang adalah sebesar 77,5% yang berarti tercapai sebagian (TS).

Background: Hospital is a healthcare institution organizing personal plenary medical service which provides inpatient, outpatient, and emergency departments. Hospitals are required to prepare, implement, and maintain the quality of their medical cares as the standard point of reference for patient care. In an attempt to improve the quality of their services, hospitals are required to conduct periodic accreditation regularly, at least once in every 3 (three) years. Based on the result of the preliminary studies through interviews with the head of the medical records unit, it was noted that the Tidar Hospital Magelang City is currently preparing to carry out the 2012�s KARS accreditation. The Patient Services Section (PP) was included as the main object to be assessed for the accreditation while its medical records unit focuses on improving the completion and documentation of the medical records. In the Tidar Hospital Magelang City, diabetes mellitus was in the top 10 diagnosis which led to hospitalizations and the results of preliminary study showed the percentage of the completeness of procedures documentation is 68% and the result of procedures is 73%, whereas the required passing score is 80%. Objective: This research was aimed to know the implementation of medical record documentation based on the PP 2.3 KARS 2012 accreditation standard in Tidar Hospital Magelang City on diabetes mellitus diagnosis. Research Method: This research uses the descriptive research method with qualitative approach and case study design. The sample used are a 100 files of the medical records of patients diagnosed with diabetes mellitus. The data are collected through interviews and documentation studies. Result : The implementation of medical record documentation based on the PP 2.3 KARS 2012 accreditation standard in Tidar Hospital Magelang City on diabetes mellitus diagnosis have been done. The Hospital has recorded the procedures and the result of procedures in medical record documents. The present documentation study on the 100 medical records showed that degree of procedures was 77% completely fulfilled, 3% incompletely, and 20% unfilled medical records. Meanwhile, the result of procedures showed that 78% completely fulfilled, 17% incompletely fulfilled, and 5% unfilled medical records.The number of completion based on the PP 2.3 KARS 2012 accreditation standard in Tidar Hospital Magelang City is 77,5%, which means partially completed.

Kata Kunci : Pendokumentasian, Rekam Medis, Akreditasi, Diabetes Melitus