Review Rekam Medis Pasien Ruang Isolasi Covid-19 RSU Imelda Pekerja Indonesia Tahun 2020

  • Mei Sryendang Sitorus Universitas Imelda Medan
  • Esraida Simanjuntak Universitas Imelda Medan
  • Valentina Valentina Universitas Imelda Medan
Keywords: Review of Medical Record Documents, Covid-19 Isolation Room

Abstract

Quantitative Analysis is a review of certain parts of the contents of medical records to find deficiencies, especially those related to the documenting of medical records. Coronavirus Disease 2019 (Covid-19) is an infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARSCoV-2). The purpose of this study is to find out the implementation of the Covid-19 Isolation Room Patient Medical Record Document Review at RSU Imelda Pekerja Indonesia in 2020. The population is all patients treated in the Covid-19 Isolation Room in 2020 as many as 182 people, the study sample is all patients treated in the Covid-19 Isolation Room in October as many as 48 people. The DRM review was conducted on four variables. From the results of the study obtained that the Review of Timeliness of appropriate DRM Returns as much as 35.41%; Review of the Accuracy of Filling out DRM for the exact Opname Warrant Form (SPO) 31.25%, the appropriate IGD Assessment Form 52.08%, the right Medical Resume Form 100%, and the proper Observation Form 66.67%; DRM Readability Review for Opname Warrant Form (SPO) which reads 100%, IGD Assessment Form that reads 77.08%, Medical Resume Form that reads 100%, and Observation Form that reads 72.92%; Drm Completeness Review for Screening Form found in 68.75% of documents, Triage Form found in 77.08% documents, Internal Transfer Form found on 89.58% of documents, Discharge Planning Form found on 81.25% of documents.For General Consent Forms, Inpatient Assessments, CPPT Forms, Observation Forms, and Information and Education Forms are found in all documents that are 100%. It is recommended that the existing SPO socialization prioritizes the accuracy of filling out medical records qualitatively, not limited to the completeness of the form only.

Downloads

Download data is not yet available.

References

[1] Permenkes RI, Permenkes RI Nomor 3/Menkes/Per/2020 tentang Klasifikasi dan Perizinan Rumah Sakit. Jakarta, 2020.

[2] Permenkes RI, Permenkes RI Nomor 269/Menkes/Per/III/2008 tentang Rekam Medis. Jakarta, 2008.

[3] Kemenkes RI., Keputusan Menteri Kesehatan Republik Indonesia Nomor 129/MenKes/SK/ /II/2008 tentang Standar Pelayanan Minimal Rumah Sakit. Jakarta, 2008.

[4] Kemenkes RI., Keputusan Menteri Kesehatan Republik Indonesia Nomor Hk.01.07/Menkes/413/2020 tentang Pedoman Pencegahan Dan Pengendalian Coronavirus Disease 2019 (Covid-19). Jakarta, p. 2020.

[5] Permenkes RI, Peraturan Menteri Kesehatan Republik Indonesia Nomor 1171/Menkes/Per/VI/2011 tentang Sistem Informasi Rumah Sakit . Jakarta, 2011.

[6] S. Notoatmodjo, Metodologi Penelitian Kesehatan. Jakarta: Rineka Cipta, 2012.

[7] Sugiyono, Metode penelitian kuantitatif. Bandung: Alfabeta, 2018.

[8] S. Notoatmodjo, Metodologi penelitian kesehatan. Jakarta: Rineka Cipta, 2010.

[9] S. Notoatmodjo, Metodologi Penelitian Kesehatan. Jakarta: Rineka Cipta, 2017.
Published
2022-08-31
How to Cite
Sitorus, M. S., Simanjuntak, E., & Valentina, V. (2022). Review Rekam Medis Pasien Ruang Isolasi Covid-19 RSU Imelda Pekerja Indonesia Tahun 2020. Jurnal Ilmiah Perekam Dan Informasi Kesehatan Imelda, 7(2), 134-143. https://doi.org/10.52943/jipiki.v7i2.988

Most read articles by the same author(s)