Tinjauan Pelaksanaan Review Berkas Rekam Medis Sesuai Standar Manajemen Informasi Dan Rekam Medik (MIRM 13.4) Di Rumah Sakit Imelda Pekerja Indonesia Tahun 2020

  • Esraida Simanjuntak Universitas Imelda Medan
  • Mustamil Alwi Dasopang Universitas Imelda Medan
Keywords: Review, Medical Record Files, Medical Record Information Management (MIRM) 13.4

Abstract

 

One of the parameters for determining the quality of health services in the hospital is data or information from good and complete medical records. Medical records are an important part of helping the implementation of service delivery to patients at the hospital. Standards relating to medical records in SNARS Edition 1 are in the group of hospital management standards, namely Medical Record Information Management (MIRM) regarding medical record document processing including provision, filling of medical records and reviewing medical records. This research method is descriptive with the method of observation. When this research was conducted in July 2020 at the Imelda Hospital Worker Indonesia Medan. The population taken was 705 medical record documents while the sample in this study was 87 medical record documents. Based on the results of the study, in the review the accuracy of returning medical record documents was 57.4% and 42.5% were incorrect. Readability review of ER assessment as much as 63.2%, assessment of Inpatient as much as 56.3%, CPPT as much as 60.9%, approval for action as much as 77%, reports of anesthesia as much as 68.9%. 3 forms of completeness review are complete, namely Education Assessment, rejection and education form (100%). Suggestions in this study are that review officers must be more assertive to remind every doctor or other medical personnel to pay attention to the accuracy of the restoration, the legibility of medical record files and the completeness of medical record documents. As well as regularly socializing the elements of the MIRM 13.4 assessment.

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References

Esraida. 2018. Analisis Ketidaklengakapan Dokumen Rekam Medis Menurut Standar Akreditasi Rumah Sakit MKI 19.1 Versi KARS 2012 di Rumah Sakit Imelda Pekerja Indonesia (RSU IPI) Medan Tahun 2018. (dalam jurnal Ilmiah Perekam Dan Informasi Kesehatan Imelda Vol. 4. No.1 tahun 2019).

Kementrian Kesehatan RI. 2020. Peraturan Menteri Kesehatan RI Nomor 3 tahun 2020 tentang klasifikasi dan perizinan rumah sakit. Jakarta

Kementrian Kesehatan RI. 2008. Peraturan Menteri Kesehatan RI Nomor 269 tahun 2008 tentang Rekam Medis. Jakarta.

Kementrian Kesehatan RI. 2015. Peraturan Kementrian Kesehatan RI Nomor 46 tahun 2015 tentang Akreditasi Puskesmas, Klinik Pratama, Tempat praktik Mnadi Dokter, dan Tempat Praktik Mandiri Dokter Gigi. Jakarta

Komite Akreditasi Rumah Sakit. 2017. Standar Nasional Akreditasi Rumah Sakit Edisi 1. Jakarta

Notoatmodjo. 2010. Pendidikan dan Perilaku Kesehatan. Jakarta. Rineka Cipta.

Notoatmodjo. 2012. Metode penelitian kesehatan. Jakarta. Rineka Cipta.

Sugiyono. 2018. Metode Penelitian Pendidikan Pendekatan Kuantitatif, kualitatif dan R&D. Bandung : Alpabeta

Undang- Undang RI. 2017. Undang-Undang RI Nomor 34 tahun 2017 tentang Akreditasi Rumah Sakit. Jakarta. Undang-Undang Republik Indonesia

Widyaningrum L. 2019. Analisis Pengelolaan Dokumen Rekam Medis Rawat Inap Berdasarkan (SNARS) Edisi 1 di RSJD DR. Arif Zainudin Surakarta. (dalam jurnal ilmiah Program Studi D3 Rekam Medik dan Informasi Kesehatan Universitas Duta Bangsa Surakarta tahun 2019) diakses tanggal 28 mei 2020.
Published
2021-02-27
How to Cite
Simanjuntak, E., & Dasopang, M. A. (2021). Tinjauan Pelaksanaan Review Berkas Rekam Medis Sesuai Standar Manajemen Informasi Dan Rekam Medik (MIRM 13.4) Di Rumah Sakit Imelda Pekerja Indonesia Tahun 2020. Jurnal Ilmiah Perekam Dan Informasi Kesehatan Imelda (JIPIKI), 6(1), 7-13. https://doi.org/10.52943/jipiki.v6i1.476