FAKTOR-FAKTOR YANG MENGHAMBAT PELAKSANAAN PELAPORAN RL 4a TERKAIT EXTERNAL CAUSES DI RUMAH SAKIT JASA KARTINI TASIKMALAYA

NEVI ARIFIYANTI, Nuryati, S.Far.,MPH

2015 | Tugas Akhir | D3 REKAM MEDIS SV

Latar Belakang: Berdasarkan Peraturan Menteri Kesehatan Republik Indonesia Nomor 1171/MENKES/PER/VI/2011 tentang Sistem Informasi Rumah Sakit (SIRS) disebutkan bahwa setiap rumah sakit wajib melaksanakan SIRS. Salah satu bentuk pelaporan rumah sakit dalam SIRS yaitu RL 4a (laporan data morbiditas pasien rawat inap). Di dalam RL 4a, terdapat laporan yang berkaitan dengan penyebab kecelakaan (external causes). RL 4a terkait external causes pada tahun 2014 di RS Jasa Kartini Tasikmalaya tidak terlaksana sehingga tidak terdapat laporan mengenai kasus kecelakaan atau trauma yang menggunakan jasa pelayanan RS Jasa Kartini Tasikmalaya. Sehingga RL 4a terkait external causes ini perlu dilaporkan. Tujuan Penelitian: Mengetahui proses pencatatan data external causes, mengetahui persentase keterisian data external causes pada rekam medis IGD, mengetahui pelaksanaan pemberian kode external causes pada rekam medis, mengetahui pembuatan pelaporan RL4a terkait external causes, mengetahui faktor yang menghambat pelaksanaan pelaporan RL 4a terkait external causes, dan mengetahui upaya dalam menangani hambatan yang dihadapi dalam pelaporan RL 4a terkait external causes. Metode Penelitian: Jenis penelitian: penelitian dekriptif dengan pendekatan kualitatif dan rancangan cross-sectional. Subjek Penelitian: petugas pelaporan, petugas coding, dokter IGD, perawat IGD, penanggung jawab IGD dan Kepala Rekam Medis. Objek penelitian: kegiatan pelaporan RL 4a terkait external causes, proses pencatatan data external causes di IGD dan proses pemberian kode external causes pada rekam medis serta rekam medis pasien yang mempunyai diagnosis berkaitan dengan BAB XIX. Teknik pengumpulan data: wawancara, observasi dan studi dokumentasi. Hasil: Pencatatan data external causes dilakukan oleh dokter IGD di lembar ringkasan. Hasil analisis pada lembar IGD, diketahui bahwa dari 130 berkas yang diteliti, external causes terisi spesifik 1 berkas, 114 tidak terisi spesifik dan 15 berkas tidak terisi. 47 berkas diantaranya hanya tertulis post KLL atau jatuh saja. Pada tahun 2014, pengodean external causes tidak dilaksanakan secara maksimal. Pembuatan laporan RL4a terkait external causes melalui tahap pengumpulan data, pengolahan data, dan penyajian data. Faktor-faktor yang menghambat pelaporan RL4a terkait external causes diantaranyapetugas IGD sibuk melayani pasien sehingga pendokumentasian external causes terabaikan, petugas koding belum paham mengenai pengodean external causes dan petugas pelaporan yang mengalami mutasi sehingga membutuhkan penyesuaian untuk pelaksanaan pelaporan RL4a terkait external causes, data external causes yang tidak tertulis secara lengkap sehingga mempengaruhi proses pengodean, lembar IGD tidak mendukung, tidak adanya software untuk mempermudah pengolahan RL4a terkait external causes. SOP pengisian rekam medis gawat darurat, kodefikasi external causes dan pelaporan RL4a terkait external causes belum diperbaharui sejak tahun 2011. Upaya yang pernah dilaksanakan diantaranya: Himbauan mencatat external causes dengan lengkap, bagian Rekam Medis konfirmasi diagnosis external causes kepada dokter IGD, pertemuan bagian instalasi rekam medis dengan bagian IGD, dan pengembangan SIMRS.

Background: Based on the Regulation of the Minister of Health of the Republic of Indonesia Number 1171/Menkes/Per/VI/2011 about Hospital Information System mentioned that every hospital is obliged to implement Hospital Information System. One form of hospital report in Hospital Information System is RL 4a (morbidity data reports inpatients). In RL 4a, there are reports relating to the causes of accidents (external causes). In 2014, RL 4a related external causes at Jasa Kartini Tasikmalaya Hospital was not implemented so there were no accidents reports that using the services Jasa Kartini Tasikmalaya hospital. Therefore RL 4a related external causes has to be reported. Goals: The research aims to identify recording process of external causes data, determine the percentage of occupancy external causes data in the emergency medical record, find out the coding implementation of external causes medical record, find out the manufacture of reporting RL4a related external causes, find out the factors that inhibit the implementation of reporting RL 4a related external causes, and find out the effort in addressing the barriers faced in reporting RL 4a related external causes. Method: Type of research: descriptive study with qualitative approach and cross-sectional design. Subject Research: reporting officer, the officer coding, emergency room doctors, emergency nurses, Chief of emergency and Chief Medical Record. The object of research: Activities of reporting RL 4a related external causes, recording process of external causes data in the emergency room and the coding process of external causes medical records and medical records of patients who have a diagnosis related to Chapter XIX. Data collection techniques: interview, observation and documentation study. Results: Recording external causes data performed by emergency room doctor in the summary sheet. The analysis of the emergency sheet, note that of the 130 files studied, external causes specific charged 1 files, 114 files is not specific and 15 files are not filled. 47 files include only written post trafict accident or only fall. In 2014, external causes coding is not carried out to the fullest. The process of making RL4a related external causes through the stages of data collection, data processing, and presentation of data. Factors that inhibit the reporting of RL4a related external causes is emergency personnel busy serving patients that neglected external causes documentation, coding officers do not understand the external causes coding and reporting officers were mutated and thus require adjustment to the implementation reporting of RL4a related external causes, external causes data that is not written in a complete so that affects the coding process, emergency sheets does not support, the absence of software to facilitate the processing of RL4a related external causes. Standar Procedure Operational of filling emergency medical record, codefication external causes and reporting related RL4a external causes have not been updated since 2011. Efforts were never implemented include: Appeal noted with a complete external causes, Medical Record Instalation confirmation diagnosis external causes to emergency doctor, meeting between the installation medical record and installation emergency room, and development SIMRS.

Kata Kunci : Factors that inhibit, Reporting, RL 4a, External causes.