INTERVENSI UNTUK MENINGKATKAN KELENGKAPAN PENGISIAN RESUME REKAM MEDIS DI RSUD BADUNG

MADE BASKARA, dr. Lutfan Lazuardi, M.Kes., PhD; dr. Hanevi Djasri, MARS

2015 | Tesis | S2 Ilmu Kesehatan Masyarakat

Latar belakang: Rekam medis adalah bagian penting penanganan pasien dan sumber informasi keadaan pasien. Rekam medis merupakan sarana komunikasi antar petugas kesehatan dalam menangani pasien. Supaya bermanfaat optimal, rekam medis harus berkualitas, salah satu syarat adalah rekam medis diisi lengkap. Keputusan Menteri Kesehatan menyebutkan, rekam medis rumah sakit harus diisi lengkap 100%. Survey unit rekam medis RSUD Badung, Januari - Nopember 2013, mengenai kelengkapan pengisian rekam medis, hasil rata-rata 83,65 %. Persentase rekam medis tidak lengkap 16,34 %. Dari semua rekam medis yang tidak lengkap, 30,82 % merupakan resume rekam medis. Perlu ada intervensi untuk memperbaiki hasil tersebut. Tujuan: Penelitian bertujuan mengidentifikasi faktor penyebab ketidaklengkapan pengisian resume rekam medis, mengidentifikasi solusi permasalahan, dan melakukan uji coba solusi permasalahan yang sudah disepakati. Diharapkan terjadi peningkatan kelengkapan pengisian resume rekam medis. Metode: Penelitian menggunakan metode action research. Siklus action research terdiri dari pre step dan empat tahapan dasar yaitu diagnosing, planning action, taking action, evaluating action. Subjek penelitian adalah seluruh resume rekam medis pasien ruang rawat inap Margapati Nopember 2013 dan Januari 2015, peserta Focus Group Discussion, Dokter Spesialis yang diwawancara. Hasil: Penyebab permasalahan adalah karakteristik individu; form rekam medis kurang simpel; tulisan tidak terbaca; standar operasional prosedur tidak jelas; kurang pemahaman aspek rekam medis; peranan dokter penanggung jawab pelayanan kurang; diagnosa tidak jelas; hari libur lebih dari satu hari; belum ada divisi hukum. Solusi permasalahan adalah pelatihan; perbaikan format rekam medis; perbaikan standar operasional prosedur; pemberian reward and punishment; penggunaan checklist; workshop rekam medis; kebijakan direktur rumah sakit; lomba kelengkapan rekam medis; pembentukan divisi hukum; penempatan petugas di ruang rawat inap. Uji coba penelitian pada Januari 2015, dengan penempatan petugas dokter umum di ruang rawat inap Margapati, didapat hasil persentase kelengkapan resume rekam medis adalah 97,82 %. Persentase kelengkapan resume rekam medis ruang rawat inap Margapati bulan Nopember 2013 adalah 91,22%. Kesimpulan dan Saran: Penempatan dokter umum di ruang rawat inap Margapati, dengan tugas memantau kelengkapan pengisian resume rekam medis, dapat meningkatkan persentase kelengkapan pengisian resume rekam medis di ruang rawat inap Margapati. Saran untuk manajemen rumah sakit, agar menempatkan dokter umum di setiap ruangan rawat inap dari rumah sakit.

Background: Medical record is an important part in the management of patient, and source of information about the patient's condition. Medical record is a means of communication among health care workers, in treating patients at the hospital. To be useful optimal, medical record must be qualified, one of the conditions is the medical record must be filled completely. Decree of the Minister of Health said, the hospital medical record must be completed 100%. Survey of the Badung General Hospital medical record section, from January until November 2013, about the completeness of the medical record, average achievement results is 83,65%. Percentage of the incomplete medical record 16,34%. From all of the incomplete medical record, 30,82% are medical record resumes. There needs to be an intervention to improve these results. Objective: The research aims to identify the factors causing incompleteness medical record resumes, identify the solutions of problems, and testing solutions of the problems that have been agreed upon. Expected to increase completeness of the medical record resume. Method: Research using action research method. The action research cycle consists a pre-step and four of basic phases, namely diagnosing, action planning, taking action, evaluating action. The research subjects were all over resumes of medical records of the Margapati inpatient unit on November 2013 and January 2015, participants of the Focus Group Discussion, Specialist Doctors that interviewed. Research Result: The cause of the problem is the individual characteristics; medical record form is less simple; illegible handwriting; standard operating procedure is not clear; lack understanding aspects of medical record; less role of the physician responsible care; the diagnosis is not clear; day off more than one day; there is no legal division. The problem solution is training; improvement of medical record form; improvement of standard operating procedure; reward and punishment; use of a checklist; medical record workshop; policy from the hospital director; race of medical record completeness; establishment of the legal division; placement officer at the inpatient unit. Research trial in January 2015, with placement the general practitioner officer in the Margapati inpatient unit, got result the completeness percentage of the medical record resumes is 97.82%. Completeness percentage medical record resumes of Margapati inpatient unit in November 2013 was 91.22%. Conclusion and Suggestion: Placement of general practitioner in the Margapati inpatient unit, with the task of monitoring the completeness medical record resumes, can increase the percentage of completeness of the medical record resumes in Margapati inpatient unit. Suggestions for hospital management, in order to put a general practitioner in every inpatient unit of the hospital.

Kata Kunci : Intervensi, Rekam Medis, Kelengkapan, Action Research