Analisis Kelengkapan Rekam Medis Pasien Rawat Inap Fraktur Tulang Anggota Gerak di Rumah Sakit Bhayangkara Denpasar

Abstract

Latar Belakang: Rekam medis adalah berkas yang memuat atas catatan serta dokumen mengenai identitas pasien, pemeriksaan, pengobatan, tindakan, dan pelayanan lain yang telah diberikan kepada pasien. Rekam medis yang lengkap bisa menunjang mutu pelayanan suatu rumah sakit. Laporan 10 besar penyakit rawat inap RS Bhayangkara Denpasar tahun 2020 yang menempati urutan pertama adalah fraktur tulang anggota gerak. Masih banyak ketidaklengkapan rekam medis pada kasus fraktur tulang anggota gerak.Tujuan: Menganalisis kelengkapan dokumen rekam medis pasien rawat inap dengan kasus fraktur tulang anggota gerak di Rumah Sakit Bhayangkara Denpasar tahun 2020.Metode Penelitian: Jenis penelitian yang dipergunakan adalah kuantitatif dengan pendekatan cross sectional. Penelitian dilaksanakan di RS Bhayangkara Denpasar pada bulan Maret-April. Sampel penelitian ini sejumlah 156 dokumen rekam medis. Teknik pengambilan sampel memakai metode systematic random sampling. Pengumpulan data memakai instrumen checklist.Hasil: Review identifikasi kelengkapan mencapai persentase 94%. Review laporan penting memiliki persentase sebesar 81%. Kelengkapan pada review autentikasi mencapai 99%. Review pendokumentasian dan pencatatan yang baik dan benar mencapai kelengkapan 94%.Kesimpulan: Kelengkapan keseluruhan sebesar 72%. Ketidaklengkapan tertinggi pada review laporan penting dan kelengkapan tertinggi ada pada review autentikasi.

The Effect of Completeness of Filling Out Important Reports on Delay in Return of Medical Record Files

“…With the availability of supporting facilities and infrastructure, it makes it easier for officers to borrow and return without any problems or obstacles in carrying out these tasks. This research was supported by the results of Wardhina and Rahmadiliyani's 16 research explaining that the cause of the delay in returning the medical record files of inpatients at Mawar General Hospital was the completeness of filling in the medical record file itself. Files before being processed by the medical record officer must ensure that the contents are complete first.…”

“…The results of the study related to the frequency of incomplete filling of important reporting showed results that were in line with Indarti and Agustia's research 15 showing that the results of a quantitative analysis of important reporting of medical record documents at RSGM Nala Husada were 84% complete and 16% incomplete. Other supporting research, namely research by Yanti and Yulianti 16 showed that the completeness of filling in the summary form of entry and exit on the patient reporting component of cases of the Internal Medicine Polyclinic had not been completed, namely the disease diagnosis item, disease code, disease history, date of admission, condition out, the action taken and the action code where the incomplete percentage of each item is 16% incomplete and 84% complete. the highest incompleteness was found in the exit date and payment method items, namely 22% incomplete and 78% complete.…”