Saripah, Wati (2021) Analisis Kelengkapan Pengisian Rekam Medis Ruang Rawat Inap di RSUD Haji Abdoel Madjid Batoe Batang Hari. S1 thesis, Prodi Ilmu Kesehatan Masyarakat.
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Abstract
Abstrak Latar Belakang: Dalam menjalankan pelayanan kesehatan, rumah sakit harus dapat menghasilkan data dan informasi kesehatan yang berguna untuk meningkatkan derajat kesehatan yang lebih baik untuk masyarakat. Satu diantara upaya untuk menghasilkan informasi kesehatan adalah dengan diselenggarakannya rekam medis. Kualitas rekam medis merupakan salah satu indikator mutu pelayanan rumah sakit yang dapat dilihat dari kelengkapan pengisian rekam medis. Tujuan penelitian adalah menganalisis kelengkapan rekam medis pasien rawat inap di RSUD Hamba Batanghari. Metode: : Jenis penelitian ini adalah kualitatif dengan pendekatan deskriptif, yaitu, berusaha mendapatakan informasi secara jelas dan tepat mengenai analisis kelengkapan pengisian rekam medis ruang rawat inap di RSUD Hamba Batanghari. Metode yang digunakan dalam pengumpulan data yang di gunakan dalam penelitian ini dilakukan dengan wawancara terstruktur, observasi dan juga telaah dokumen. Informan dalam penelitian ini berjumlah 7 orang. Informan dipilih dengan teknik purposive sampling yang terdiri dari 1 kepala bagian rekam medis, dokter, perawat dan staff bagian rekam medis 4 orang). Data dikumplkan dengan wawancara mendalam Triangulasi dilakukan dengan sumber dan data. Analisa data dilakukan dengan tematic analisis. Hasil: Berdasarkan hasil wawancara didapatkan bahwa pada proses input terdapat kendala dari komponen SDM dan sarana serta prasarana yaitu anggaran/dana yang pengadaannya belum terealisasi. Pada komponen proses, pengisian rekam medis tidak lengkap dikarenakan pada ringkasan pulang pasien sering terjadi kelalaian dari tenaga kesehatan yang melakukan tindakan. Sehingga rekam medis pasien rawat inap di RSUD Hamba Batanghari tergolong tidak lengkap yakni sebesar 85.78%. Ketidaklengkapan ini tentu akan berdampak secara luas baik internal maupun secara eksternal. Kesimpulan: Disarankan rumah sakit terutama bagian umum untuk memperhatikan kebutuhan dari bagian rekam medis, pengadaan seperti penambahan SDM dengan kualifikasi pendidikan rekam medis, mengadakan pelatihan rekam medis, dan melengkapi sarana serta prasarana rekam medis seperti penambahan computer, dan memperkuat jaringan internet. Disamping itu perlu menigkatkan pengwasan kepada petugas dalam melaksanakan SOP rekam medis. Kata Kunci: Rekam Medis, Rawat Inap, Rumah Sakit, Kualitatif ABSTRACK Background: In carrying out health services, hospitals must be able to produce health data and information that is useful to improve the degree of better health for the community. One of the efforts to produce health information is the holding of medical records. The quality of medical records is one indicator of the quality of hospital services that can be seen from the completeness of filling out medical records. The purpose of the study was to analyze the completeness of the medical records of hospitalization room at the RSUD Hamba Batanghari. Methods: : This type of research is qualitative with a descriptive approach, namely, trying to obtain clear and precise information regarding the analysis of the completeness of filling out medical records in the inpatient room at Hamba Batanghari Hospital. The method used in collecting data used in this study was conducted by structured interviews, observation and document review. There were 7 informants in this study. Informants were selected by purposive sampling technique which consisted of 1 head of the medical records section, doctors, nurses and 4 staff members of the medical records department). Data was collected by in-depth interviews. Triangulation was carried out with sources and data. Data analysis was carried out by thematic analysis. Results: Based on the results of interviews, it was found that in the input process there were obstacles from the components of human resources and facilities and infrastructure, namely the budget/funds whose procurement had not been realized. In the process component, filling out the medical record was in completed because in the summary of the patient's discharge there is often negligence from the professional personnel who take the action. So that the medical records of hospitalization room at the Hamba Hospital Batanghari are incomplete, which is 85.78%. This incompleteness will certainly have a broad impact both internally and externally. Conclusion: It is recommended that hospitals, especially the general department, pay attention to the needs of the medical record section, procurement such as adding human resources with medical record education qualifications, holding medical record training, and completing medical record facilities and infrastructure such as adding computers, and strengthening internet networks. In addition, it is necessary to increase supervision of officers in carrying out medical record SOP. Keywords: Medical Record, Inpatient, Hospital, Qualitative
| Type: | Thesis (S1) |
|---|---|
| Subjects: | L Education > L Education (General) |
| Divisions: | Fakultas Kedokteran dan Ilmu Kesehatan > Ilmu Kesehatan Masyarakat |
| Depositing User: | Wati Saripah |
| Date Deposited: | 27 Apr 2022 06:00 |
| Last Modified: | 27 Apr 2022 06:00 |
| URI: | https://repository.unja.ac.id/id/eprint/25268 |
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