Gambaran Kelengkapan Dokumen Rekam Medis Pasien Rawat Inap

Abstract

The study was conducted by doing the quantitative and qualitative analysis of the medical records document of inpatients in Semarang Hospital. The approach of the research was Retrospective approach. We used the purposive sampling in 15 inpatient ward. The research variables include all components of the reviews in the quantitative analysis and qualitative analysis. The results of the quantitative analysis shows that there are some incompleteness of medical record documents in the inpatient unit including charging documents, writer authentication, and inappropriate recording based on the regulations. From the result of the qualitative analysis, it can be concluded that there is consistency of recording the statement of diagnosis and treatment as well as recording the direction of informed consent. It require socialization to health workers who are in charge to fill the medical record documents about the importance of filling out the medical record completely and correctly, and to conduct an audit of medical records on a regular basis to improve the quality of medical record documents in the inpatient unit.

Keywords: Medical records, quantitative analysis, qualitative analysis


Abstrak

Penelitian dilakukan dengan melakukan analisis kuantitatif dan analisis kualitatif terhadap dokumen Rekam Medis pasien rawat inap di RS “A” Semarang. Rancangan penelitian dengan pendekatan Retrospektif. Menggunakan Purposive Sampling di 15 ruang perawatan rawat inap. Variabel penelitian meliputi seluruh komponen review dalam analisis kuantitatif dan analisis kualitatif. Hasil penelitian analisis kuantitatif menunjukkan bahwa masih ditemukan ketidaklengkapan dokumen Rekam Medis di ruang rawat inap dalam hal pengisian dokumen, autentikasi penulis, dan ketidaksesuaian dalam melakukan pencatatan sesuai dengan ketentuan yang berlaku. Hasil analisis kualitatif terhadap dokumen Rekam Medis rawat inap dapat disimpulkan bahwa terdapat konsistensi pernyataan diagnosis konsistensi pencatatan dan arah pengobatan serta pencatatan informed consent. Diperlukan sosialisasi kembali kepada petugas kesehatan yang berwenang mengisi dokumen Rekam Medis tentang pentingnya mengisi dokumen Rekam Medis dengan lengkap dan benar, serta dilakukan audit Rekam Medis secara berkala untuk meningkatkan kualitas dokumen Rekam Medis di ruang rawat inap.

Kata kunci: Rekam Medis, analisis kuantitatif, analisis kualitatif