TELAAH REKAM MEDIS TERTUTUP TERKAIT CONSENT PASIEN BEDAH BERDASARKAN STANDAR KARS 2012 DI RUMAH SAKIT UNIVERSITAS GADJAH MADA

ARIKA ERMAWATI, Savitri Citra Budi, SKM., MPH

2016 | Tugas Akhir | D3 REKAM MEDIS SV

Latar Belakang: Kelengkapan pengisian consent sangat penting karena merupakan salah satu aspek yang dinilai dalam standar KARS 2012. Formulir consent menyediakan bukti tertulis bahwa pasien menyetujui prosedur-prosedur yang tertulis disana. Formulir consent khususnya pada pasien bedah yang terisi lengkap mencerminkan bahwa hak pasien maupun keluarga sudah terpenuhi yang artinya mereka telah menerima informasi yang dibutuhkan atas tindakan kedokteran yang akan dilakukan, hal tersebut juga berpengaruh terhadap mutu layanan rumah sakit. Standar akreditasi KARS 2012 merupakan indikator untuk mengukur mutu layanan rumah sakit dan telaah rekam medis tertutup merupakan salah satu aspek yang akan disurvei. Tujuan: Penelitian ini bertujuan untuk mengetahui pelaksanaan consent pada pasien bedah berdasarkan standar KARS 2012, persentase kelengkapan rekam medis tertutup terkait consent pasien bedah, serta faktor penyebab ketidaklengkapan pengisian consent. Metode Penelitian: Jenis penelitian yang digunakan adalah penelitian deskriptif dengan pendekatan kualitatif dan rancangan penelitian studi kasus. Subjek penelitian ini adalah petugas TPP rawat inap, dokter bedah, dokter anestesi, perawat ruangan, dan petugas analisis & assembling. Pengambilan sampel objek dalam penelitian ini menggunakan purposive sampling. Teknik pengumpulan data menggunakan teknik studi dokumentasi, wawancara, dan observasi. Validasi data menggunakan triangulasi sumber dan teknik. Penelitian ini dilakukan di Instalasi Rekam Medis dan Gatotkaca 3 Rumah Sakit Universitas Gadjah Mada. Hasil: Pelaksanaan consent di Rumah Sakit Universitas Gadjah Mada telah dilaksanakan sesuai standar KARS 2012, hal ini didukung dengan adanya persetujuan dan pemberian informasi sebelum dilakukan tindakan medis. Hasil persentase kelengkapan consent pada pasien bedah untuk standar HPK 6.3 25,88%, standar HPK 6.4 terkait persetujuan operasi dan tindakan medik 51,76%, persetujuan anestesi dan sedasi 65,88%, PAB 5.1 terkait risiko, keuntungan, dan anestesi alternatif sebesar 90,58%, sedangkan standar PAB 7.1 risiko, keuntungan, komplikasi, dan alternatif operasi sebesar 89,41%. Faktor yang menyebabkan ketidaklengkapan pengisian yaitu kesibukan individu dalam pengisian consent, keterbatasan jumlah SDM untuk TPP rawat inap, ketidaksesuaian item saksi pada formulir general consent, serta kurangnya sosialisasi dari pihak rekam medis dan pokja HPK & PAB terkait pengisian formulir informed consent. Kesimpulan: Pelaksanaan consent di Rumah Sakit Universitas Gadjah Mada telah dilaksanakan sesuai standar KARS, kelengkapan tertinggi telaah rekam medis tertutup pada consent terdapat pada PAB 5.1. Faktor yang menyebabkan ketidaklengkapan pengisian yaitu dapat dilihat dari aspek SDM, formulir consent, serta prosedur dan kebijakan.

Background: Completeness of the filling of consent is very important because it is one of the aspect that is assessed in standarized KARS 2012. Consent form provide written evidence that patients agree to procedures is written there. Consent form particularry in surgical patients of the completed reflects that the rights of patients and families are met, which means they have received the necessary information on medical action to be taken, it would also affect the quality of hospital service. KARS standars in 2012 is an indicator for measuring the quality of hospital services and closed medical record review sealed is one aspect to be surveyed. Objective: This research aimed to know the implementation of consent in surgical patients based on the standard KARS 2012, the percentage of completeness consent of surgical patients filling based on closed medical record review KARS standards 2012, and knowing the factors that cause incomplete filling consent of surgical patients. Method: This type of research is a descriptive study with qalitative approach and case study research design. Subjects in this study were officers inpatient admission, surgeons, anesthetists, nurse room, and analysis and assembling officers. Sampling object in this research using purposive sampling. For collecting data techniques using the techniques of study documentation, interviews, and observations. For the validation of data using triangulation sources and techniques. This research was conducted in the Installation Medical Record and Gatotkaca 3 in Gadjah Mada University Hospital. Results: Implementation of consent at Gadjah Mada University Hospital has implemented according to standard KARS 2012, it is supported by the approval and provision of information prior to a medical procedure. The percentage of completeness of consent in surgical patients for HPK 6.3 standard by 25.88%, HPK 6.4 standard related approval operations and medical action by 51.76%, the approval of anesthesia and sedation 65.88%, PAB 5.1 risks, benefits, and anesthesia alternative by 90.58%, PAB 7.1 standars associated risks, benefits, complications, and alternative operations by 89.41%. Factors that cause incomplete filling that the busyness of individuals in filling consent, limited number of human resources for officers inpatient admission, mismatches witness item on the form of general consent, and lack of socialization of the medical records and working groups of HPK & PAB related filling informed consent form. Conclusions: Implementation of consent at Gadjah Mada University Hospital has implemented according to standard KARS, the highest completeness of closed medical record review on PAB 5.1. Factors that led to incomplete filling that can be seen from the aspect of human resource, consent forms, and procedure & policies.

Kata Kunci : Telaah rekam medis tertutup, consent pasien bedah, standar KARS 2012, pelaksanaan, faktor penyebab.