HUBUNGAN BEBERAPA FAKTOR KELENGKAPAN PENGISIAN DOKUMEN REKAM MEDIS RAWAT INAP TERHADAP MUTU DOKUMEN REKAM MEDIS DI BADAN RSUD BANJARNEGARA PEBRUARI 2005

YUNIARTI, SRI (2005) HUBUNGAN BEBERAPA FAKTOR KELENGKAPAN PENGISIAN DOKUMEN REKAM MEDIS RAWAT INAP TERHADAP MUTU DOKUMEN REKAM MEDIS DI BADAN RSUD BANJARNEGARA PEBRUARI 2005. Undergraduate thesis, Diponegoro University.

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Abstract

Akreditasi Rumah Sakit merupakan salah satu cara untuk mendapatkan gambaran seberapa jauh rumah sakit di Indonesia telah memenuhi berbagai standar yang ditentukan. Salah satu standar pelayanan yang ditetapkan oleh Departemen Kesehatan adalah Standar Pelayanan Rekam Medis. Dalam Standar Pelayanan Rekam Medis terdapat instrumen penilaian mengenai evaluasi dan pengendalian mutu yaitu penghitungan Angka Ketidak Lengkapan Pengisian Catatan Medis (KLPCM). Angka Ketidak Lengkapan Pengisisan Catatan Medis di Badan RSUD Banjarnegara selama tahun 2004 mengalami peningkatan setiap bulannya. Tujuan penelitian ini adalah untuk mengetahui hubungan beberapa faktor kelengkapan pengisian dokumen rekam medis rawat inap terhadap mutu dokumen rekam medis rawat inap di Badan RSUD Banjarnegara. Penelitian ini merupakan penelitian penjelasan (explanatory research). Metode yang dipakai adalah metode Crossectional study. Sedangkan sistim pengambilan sampel pada 171 responden adalh menggunakan Simple Random Sampling. Data dikumpulkan adalah data Sekunder. Analisa data dilakukan secara deskriptif dan analitik. Penelitian ini memperoleh hasil bahwa dokumen rekam medis yang tidak bermutu sebesar 60,8% dari total responden. Setelah dilakukan Uji Chi Square diperoleh hasil bahwa ada hubungan yang bermakna ketepatan penetuan diagnosa awal (p=0,001), Ketepatan penentuan kode penyakit (p=0,001), Pencatatan Inform Consent (p=0,001), Pencatatan riwayat medis pasien (p=0,001), Pencatatan Resume Medis Akhir (p=0,001), Pencatatan Catatan Perawat (p=0,001), Pencatatan Grafik Temperatur dan Nadi (p=0,004), dan Pencatatan Pemberian Obat dan Cairan (p=0,001) dengan mutu dokumen rekam medis. Berdasarkan hasil penelitian maka saran yang bisa disampaikan adalah perlu diadakan pembinaan kepada dokter dalam hal pengisian dokumen rekam medis dan memberikan pembinaan kapada dokter dalam hal pengisian dokumen rekam medis dan memberikan palatihan interen mengenai penentuan diagnosis utama sesuai dengan ketentuan ICD-10. Sub Bidang Rekam Medis agar membuat surat pemberitahuan kepada dokter yang belum melengkapi pencatatan dokumen rekam medis di ruang Sub. Bidang Rekam Medis, sehingga persentase angka Ketidak Lengkapan Catatan Medis (KLPCM) dapat diperkecil sampai 0%. Kepada peneliti lain agar melakukan penelitian lebih lanjut dengan variabel yang lain (tenaga, pengetahuan, motivasi, pola pembinaan, pendidikan) untuk menambah referensi dalam hal mutu dokumenrekam medis. Kata Kunci: Kelengkapan pengisian dokumen Rekam Medis Rawat Inap. THE RELATION SEVERAL FACTOR OF COMPLETION OF ADMISSION FILLING THE MEDICAL RECORD DOCUMENT OF TAKE CARE OF TO LODGE TOWARD THE MEDICAL RECORD QUALITY IN RSUD BANJARNEGARA FEBRUARY 2005 The Hospital Accreditation is one way to get description how far hospital in Indonesia has fulfilled varicous determined standard. One of the service standard specified by Health Departement is medical record service standard. In medical record service standard there are assassment instrument concerning evaluation evaluation and quality control that is enumeration of the medical record incomplete value (KLPCM). The medical record in complete value in BRSUD Banjarnegara during 2004 is increase per mont. The Objective of this research is to know relationship several factor of completion of admission filling the record document of take care of to lodge toward medical record quality in BRSUD Banjarnegara. This research is explanatory research. Used method is Crossectional Study Method. While the sampling system at 171 responder by using Sample Random Sampling. The collected data are secondary data. Data analysis are by descripively and analytic. Thie research get result that unquality medical record document are equal to 60.8% of total responder. After Chi Square Test obtained result that there is a meaning relationship the determination accurancy of initial diagnose (p=0,001), determination accuracy of desease code (p=0,001), Inform concent Record (p=0,001), Medical History of Patient (p=0,001), finish medical resume record (p=0,001), nurse record (p=0,001), temperature and artery graph record (p=0,004), and giving medicine and dilution record (p=0,001), with quality of medical record document. According to the result of the research, thre are some suggestion that should be done the doctor should be given guidance in filling medical record document and given internal training concerning the determination of main diagnoses which fit with ICD-10. Medical Record Sub. Departement Makes Notice to the doctor who has not completed the record of medical record documents in that Medical Record Sub. Departement room, so that the percentage of incomplete of medical record (KLPCM) can be minimized until 0%. To other researcher should conduct furthermore research with another variable (worker, knowledge, motivation, construction pattern, education) to add reference about the quality of medical record ducuments. Keyword : The Completion of Admission Filling the Medical Record Document of Take Care of to Lodge.

Item Type:Thesis (Undergraduate)
Subjects:R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine
Divisions:Faculty of Public Health > Department of Public Health
ID Code:8997
Deposited By:admin FKM undip
Deposited On:22 Apr 2010 09:31
Last Modified:22 Apr 2010 09:31

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