Analisa Ketidaklengkapan Catatan Medis (KLPCM) Rawat Inap Pasien Bedah Orthopedi di RSUD Sultan Sulaiman Serdang Bedagai Tahun 2018Analisa Ketidaklengkapan Catatan Medis (KLPCM) Rawat Inap Pasien Bedah Orthopedi di RSUD Sultan Sulaiman Serdang Bedagai

  • Puput Melati Hutauruk STIKes Imelda
  • Nurul Husna STIKes Imelda
Keywords: Medical Record, inpatient

Abstract

Completeness of medical records is one indicator of the quality of medical records, especially inpatient medical records. The presence of incomplete problems is often found in inpatients, especially orthopedic surgery. To improve health services in orthopedic surgery patients must be based on quality medical record services. This study aims to determine the number of incomplete medical records of inpatient orthopedic surgery patients at Sultan Sulaiman Hospital Serdang Bedagai. This study uses a descriptive method that is a method of research conducted with the main objective to determine the number of incomplete medical records inpatient filling in orthopedic surgery patients. From the results of the study it was found that the incompleteness of filling in the integrated record form was 18.47%, the initial assessment was 17.39%. medical resume is 10.87% and informed consent is 11.95%. The doctor's name is19.56% and the doctor's signature is 7.60% while for the patient's identification. the anesthesia record and the operation report are filled in completely. The advice from the author is a fixed procedure Analysis of incompleteness Filling inpatient medical records needs to be revised so that all forms are analyzed. and it is necessary to carry out continuous socialization.

References

Aditama., 2010, Manajemen Administrasi Rumah Sakit. Universitas Indonesia, Jakarta.

Agustina., 2011, Karya Tulis Ilmiah: Perancangan dan Prosedur Penggunaan Petunjuk Keluar (Outguide) untuk Penyimpanan Rekam Medis Rawat Jalan di RS Batu Zalech Martapura, Stikes Husada Borneo, Banjarbaru.

Arikunto, S., 2010, Prosedur Penelitian Suatu Pendekatan Praktik, Rineka Cipta, Jakarta.

Budi, S., 2011, Manajemen Unit Kerja Rekam Medis, Quantum Sinergis Media, Yogyakarta.

Bustami, 2011, Penjaminan Mutu Pelayanan Kesehatan dan Akseptabilitasnya, Erlangga, Jakarta.

Departemen Kesehatan Republik Indonesia, 2006, Pedoman Penyelenggaraan dan Prosedur Rekam Medis Rumah Sakit di Indoensia, Revisi ke-2, Depkes RI, Jakarta.

Departemen Kesehatan RI, Direktorat Pelayanan Medik, 2008, Pedoman Pengelolaan Rekam Medis Rumah Sakit Di Indonesia, Revisi I, Depkes RI, Jakarta.

Firdaus, 2008, Rekam Medis dalam Sorotan Hukum dan Etika. LPP UNS dan UNS Press. Surakarta.

Giyana, F, 2012, Analisis Sistem Pengelolaan Rekam Medis Rawat Inap Rumah Sakit Umum Daerah Kota Semarang.

Hatta., 2013, Pedoman Manajemen Informasi Kesehatan Di Sarana Pelayanan Kesehatan. UI-Press, Jakarta.

Huffman, E.K., 1999, Health Information Management, Edisi 10, Millionis; Physician Record Company.

Karyoto., 2016, Dasar-Dasar Manajemen Teori Definisi Dan Konsep. Andi Offset, Yogyakarta.

Kemenkes RI, 2008, Peraturan Menteri Kesehatan Republik Indonesia Nomor 269/MENKES/PER/III/2008, Kemenkes RI, Jakarta.

Keputusan Menteri Kesehatan RI No. 129, 2008, Standar pelayanan minimal rumah sakit, Kemenkes RI, Jakarta.

Published
2019-12-30
Section
Articles