Analisis Kelengkapan Pengisian Resume Medis Rawat Inap di RS Darurat Covid-19 Wisma Atlet Kemayoran
Abstract
The completeness of medical records is very important to affect the process of services provided by health workers and impact on the quality of services of a hospital. Preliminary study results conducted at RSDC Wisma Atlet Kemayoran, filling out medical resume form 5 out of 10 files no signature name of medical resume form. Also found, 3 out of 10 files have no outgoing diagnostic information. The purpose of this study is to identify the completeness of the patient's identity, review of important reports, authenticity review and review of the correct completeness of the medical resume form at RSDC Wisma Atlet Kemayoran. This research is qualitative research. The study subject consisted of 2 doctors who filled out a medical resume. The object of the study was a sample of inpatient medical records from June 7-21, 2021 based on slovin formula as many as 98 files. The results of the study on the completeness of filling a medical resume seen from 4 aspects have not been high enough. Incomplete filling of medical resume forms is influenced by several factors, namely man, methode, material, and machine factors.
Downloads
References
Pemerintah Indonesia, “Undang-undang No 44 Tahun 2009 tentang Rumah Sakit,” Lembaran Negara RI, 2009.
Kementerian Kesehatan Republik Indonesia, “Permenkes No. 269/Menkes/PER/III.2008,” Kemenkes RI, 2008.
Giyana, Frenti. "Analisis Sistem Pengelolaan Rekam Medis Rawat Inap Rumah Sakit Umum Daerah Kota Semarang." Jurnal Kesehatan Masyarakat Universitas Diponegoro 1.2: 18739, 2012.
Nurhaidah, Nurhaidah, Tatong Harijanto, and Thontowi Djauhari. "Faktor-Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Rawat Inap di Rumah Sakit Universitas Muhammadiyah Malang." Jurnal Kedokteran Brawijaya 29.3: 258-264, 2016.
Kementerian Kesehatan Republik Indonesia, “Kepmenkes No. 129 Tahun 2008.” Kemenkes RI, 2008.
Sugiyanto, Sugiyanto, et al. "Analisis Kuantitatif Kelengkapan Pengisian Formulir Resume Medis Pasien Rawat Inap Tahun 2015 Di RSUD RA Kartini Jepara." Jurnal Rekam Medis dan Informasi Kesehatan 1.1: 1-4, 2018.
Rahmadhani, Izha Sukma, Sri Sugiarsi, and Antik Pujihastuti. "Faktor penyebab ketidaklengkapan dokumen rekam medis pasien rawat inap dalam batas waktu pelengkapan di Rumah Sakit Umum Daerah Dr. Moewardi Surakarta." Rekam Medis 2.2. 2008.
Mekarisce, Arnild Augina. "Teknik Pemeriksaan Keabsahan Data pada Penelitian Kualitatif di Bidang Kesehatan Masyarakat." Jurnal Ilmiah Kesehatan Masyarakat: Media Komunikasi Komunitas Kesehatan Masyarakat 12.3: 145-151, 2020.
Lily Wijaya, Lily Wijaya, and Deasy Rosmala Dewi Deasy Rosmala Dewi. "REKAM MEDIS DAN INFORMASI KESEHATAN (RMIK)." 2017.
Hatta, Gemala R. "Pedoman Manajemen Informasi Kesehatan di sarana pelayanan kesehatan." Jakarta: Universitas Indonesia, 2008.
Rizkika, Maysyarah Yolla. "Analisis Kuantitatif Kelengkapan Dokumen Rekam Medis Pasien Rawat Inap Dengan Diagnosa Fracture Femur Di RSUD Dr. RM Djoelham Binjai." Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) 5.1: 62-71, 2020.
Swari, Selvia Juwita, et al. "Analisis Kelengkapan Pengisian Berkas Rekam Medis Pasien Rawat Inap RSUP Dr. Kariadi Semarang." ARTERI: Jurnal Ilmu Kesehatan 1.1: 50-56, 2019.
Winarti, Supriyanto S. "Analisis Kelengkapan Pengisian dan Pengembalian Rekam Medis Rawat Inap Rumah Sakit." Jurnal Administrasi Kesehatan Indonesia 1.4: 345-351, 2013.
Herisa, Dyas Candra. "Analisis Kelengkapan Rekam Medis Rawat Inap Di Rumah Sakit Umum Rizki Amalia Kulon Progo Yogyakarta Tahun 2017." 2017.
Hakman, Hakman, Suhadi Suhadi, and Nani Yuniar. "Pengaruh Beban Kerja, Stres Kerja, Motivasi Kerja Terhadap Kinerja Perawat Pasien Covid-19." Nursing Care and Health Technology Journal (NCHAT) 1.2: 47-54, 2021.
WIDYASTUTI, RINA. LITERATURE REVIEW: ANALISIS KELENGKAPAN PENGISIAN BERKAS REKAM MEDIS PASIEN RAWAT INAP DI RUMAH SAKIT INDONESIA. Diss. Universitas Gadjah Mada, 2021.
Santoso, May Dwi Yuri. "STUDI FENOMENOLOGI PENGALAMAN PERAWAT DALAM MERAWAT PASIEN SUSPECT COVID-19." Jurnal Ilmu Keperawatan Medikal Bedah4.1: 54-68, 2021.
Copyright (c) 2022 Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
