ANALISIS KETERISIAN DAN KETERCAPAIAN ELEMEN PENILAIAN FORMULIR REKAM MEDIS GAWAT DARURAT TERKAIT PERSIAPAN AKREDITASI KARS 2012 DI RUMAH SAKIT PKU MUHAMMADIYAH YOGYAKARTA

NINO BAMBANG S, Nuryati, S.Far., MPH.

2015 | Tugas Akhir | D3 REKAM MEDIS SV

Latar Belakang: Rumah Sakit sebagai salah satu institusi pelayanan kesehatan dituntut untuk memberikan pelayanan kesehatan yang aman, bermutu, anti diskriminasi, dan efektif dengan mengutamakan kepentingan pasien sesuai dengan standar pelayanan Rumah Sakit. Dalam upaya peningkatan mutu pelayanan maka rumah sakit wajib mengikuti akreditasi tiga tahun sekali. Dalam fasilitas pelayanan rumah sakit, terdapat pelayanan Unit Gawat Darurat (UGD) yang bertugas untuk menerima pasien yang membutuhkan perawatan segera (emergency) dan korban kecelakan (casualty). Penekanan pada UGD adalah menolong pasien secepatnya demi menyelamatkan nyawanya. Dalam standar akreditasi kelompok standar manajemen rumah sakit terdapat standar yang mengatur mengenai isi rekam medis, termasuk isi rekam medis gawat darurat, yaitu pada standar akreditasi KARS Manajemen Komuniksi dan Informasi 19.1.1 yang berisikan rekam medis gawat darurat (IGD) wajib mencantumkan jam kedatangan, kesimpulan akhir pengobatan, keadaan pulang pasien, tindak lanjut. Tujuan: Penelitian ini bertujuan untuk mengetahui gambaran keterisian dan ketercapaian elemen penilaian formulir rekam medis gawat darurat terkait persiapan akreditasi KARS 2012 di rumah sakit PKU Muhammadiyah Yogyakarta. Metode Penelitian: Jenis penelitian ini adalah penelitian deskriptif dengan pendekatan kualitatif dengan rancangan penelitian studi kasus. Subjek dalam penelitian ini adalah dokter IGD, perawat IGD, petugas pendaftaran pasien, petugas assembling, kepala instalasi rekam medis. Objek dalam penelitian ini adalah 120 berkas rekam medis gawat darurat. Teknik pengumpulan data dalam penelitian ini menggunakan teknik studi dokumentasi, wawancara, dan observasi. Untuk validasi data menggunakan triangulasi teknik. Hasil: Penelitian ini menunjukkan bahwa formulir gawat darurat tidak terdapat item kondisi pulang. Dalam pelaksanaan pengisian formulir gawat darurat diketahui keterisian lengkap jam kedatangan pasien sebesar 47,5%, keterisian lengkap diagnosa akhir sebesar 10%, dan keterisian tindak lanjut sebesar 94%. Kata Kunci: analisis, formulir, rekam medis, gawat darurat, standar akreditasi rumah sakit 2012,

Background: Hospital, as one of the health care institution, is required to provide health services that are safe, high quality, anti discrimination, and effective by giving priority to the patients needs based on the standart of hospital services. In order to improve the quality of services, the hospital must have an accreditation every three years. In the hospital facilities, there is Emergency Unit (EU) that is in charge to give emergency care to patients who need it and also victims of accident (casualty). The emphasize on EU is helping patients as soon as possible in order to safe their lives. In the standart of accreditation of hospital management, there is one that governs the content of medical records, including the medical records of EU, in the KARS accreditation standart of communication management and information 19.1.1 which contains the EU medical records that includes arrival time, treatment results, patients leaving condition, and the follow-up. Objectives: This research is aimed to know the occupancy and achievement elemets on assesment form of EU medical records, related to the preparation of KARS accreditation 2012 in PKU Muhammadiyah Yogyakarta hospital. Method of Research: This is a descriptive research with qualitative approach and research designing case of study. The subjects in this study are EU doctors, EU nurses, registration officer, assembling officer, the head of medical records. The object is 120 documents of EU medical records. Method of collecting the data is documentation, interview, and observation. To validate the data, triangulation technique is used. Results: The result of this research shows that EU forms do not contain the returning condition of the patients. In filling the EU form, known that the complete occupancy of patients arrival time is 47,5%, complete occupancy of final diagnose is 10%, and follow-up complete occupancy is 94%. Keywords: analysis, form, medical record, emergency, standard accreditation hospital 2012

Kata Kunci : analysis, form, medical record, emergency, standard accreditation hospital 2012