GAMBARAN KETIDAKLELENGKAPAN PENGISIAN FORMULIR LAPORAN ANESTESI KASUS BEDAH DI RSU IMELDA PEKERJA INDONESIA MEDAN

  • Valentina Dosen APIKES Imelda
  • Sri Mulia Melayu Universitas Imelda Medan
Keywords: incompleteness, forms, anesthesia, surgical, medical record

Abstract

Every health service provided to patients must recorded in the medical records completely because the completeness of filling the medical record is used as an indicator of the quality of health services in the hospital. The purpose of this study is to determine the incomplete picture of filling out an anesthetic case report form in a surgical case at the Imelda Indonesian Workers Hospital in Medan. The type of research is descriptive. The populations of this study are all forms of anesthesia patient case reports for the first quarter of 2020 with a total of 728 forms. The samples are 88 forms taken using systematic random sampling. Data collection was carried out using the checklist sheet. Data were analyzed univariate to describe the characteristics of each research variable by producing a frequency distribution and percentage of each variable. The results showed that there were 24 anesthetized report forms that were completely filled and 64 anesthetic report forms that were not completely filled. The highest percentage of incompleteness of filling in the patient identity component on the item date of birth was 10 forms (11%), on the anesthesia time component on the old surgical item by 39 forms (44%), on the diagnostic component on the post-surgical diagnostic item by 28 forms (32%), the examination component on the preoperative state item was 63 forms (72%) and the signature component was 2 forms (2%). It is recommended that every health worker who provides health services to surgical case patients fill out the anesthetic report form in accordance with the SPO authorizing the medical record filling, and to the medical record officer to conduct an assembling or complete analysis of medical record documents.

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References

Keputusan Menteri Kesehatan RI No. 129/Menkes/SK/II/2008. Standar Pelayanan Minimal Rumah Sakit. Jakarta: Kemenkes RI

Peraturan Menteri Kesehatan RI No. 4 Tahun 2018. Kewajiban Rumah Sakit dan Kewajiban Pasien. Jakarta: Kemenkes RI

Kemenkes RI. 2008. Peraturan Menteri Kesehatan No. 269/MENKES/PER/III/2008. Rekam Medis. Jakarta: Kemenkes RI

Febrianti LN, Sugiarti I. 2019. Kelengkapan Pengisian Formulir Laporan Operasi Kasus Bedah Obgyn sebagai alat bukti hukum. Jurnal Manajemen Informasi Kesehatan Indonesia. Vol. 7. No. 1. Maret 2019: 1-9.

Febriyanti IM, Sugiarti I. 2015. Analisis Kelengkapan Pengisian Data Formulir Anamnesis Dan Pemeriksaan Fisik Kasus Bedah. Jurnal Manajemen Informasi Kesehatan Indonesia. Vol. 3. No. 1. Maret 2015: 31-37.

Hasibuan AS, Malau G. 2019. Ketidak Lengkapan Dokumen Rekam Medis Rawat Inap Pada Pasien Diabetes Mellitus Di Rsu Imelda Medan. Jurnal Ilmiah Perekam Dan Informasi Kesehatan Imelda. Vol. 4. No. 2. September 2019: 675-679.

Herfiyanti L, Ninda RC. 2019. Pengaruh Kelengkapan Pengisian Formulir Informed Consent Anestesi Pasien Rawat Inap Terhadap Pemenuhan Standar Nasional Akreditasi Rumah Sakit (SNARS-1) HPK 5.2 di Rumah Sakit Umum Pindad Bandung. Teras Kesehatan. Vol. 1. No. 2. Januari 2019: 89-98.

Lubis F. 2017. Tinjauan Ketidaklengkapan Penulisan Resume Medis Rawat Inap di Rumah Sakit Umum Imelda Pekerja Indoneisa (IPI) Medan Tahun 2016. Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda. Vol. 2. No. 1. Februari 2017: 229-234.

Maliki A, Saimi, Purnama H. 2018. Analisis Ketidaklengkapan Dokumen Rekam Medis Pada Kasus Rawat Inap di RSUD Patut Patuh Patju Gerung. Jurnal Kesehatan Qamarul Huda. Vol. 6. No. 1. Juni 2018: 17-23.

Swari SJ, Alfiansyah G, Wijayanti RA, Kurniawati RD. 2019. Analisis Kelengkapan Pengisian Berkas Rekam Medis Pasien Rawat Inap RSUP Dr. Kariadi Semarang. Jurnal Ilmu Kesehatan. Vol. 1. No. 1. Nopember 2019: 50-56.
Published
2020-08-31
How to Cite
Valentina, & Melayu, S. M. (2020). GAMBARAN KETIDAKLELENGKAPAN PENGISIAN FORMULIR LAPORAN ANESTESI KASUS BEDAH DI RSU IMELDA PEKERJA INDONESIA MEDAN. Jurnal Ilmiah Perekam Dan Informasi Kesehatan Imelda, 5(2), 149-155. https://doi.org/10.2411/jipiki.v5i2.415

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