Tinjauan Kelengkapan Pengisian Formulir Assesment Awal Poli Klinik Pasien Rawat Jalan Menggunakan Metode IAR

Safitri, Dinda Melani; Fannya, Puteri; Indawati, Laela; Dewi, Deasy Rosmala

doi:10.36418/cerdika.v2i4.371

Cited by 3 publications

(5 citation statements)

References 3 publications

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“…The incompleteness of the initial outpatient assessment documentation in this study was much higher than in previous studies. A previous study by Safitri in 2022 in an outpatient unit showed a completeness rate of 77% (12), and a study by Rajaa at Basra General Hospital identified the incomplete filling of the initial assessment in the medical record, reaching 78% (13).…”

Section: Discussionmentioning

confidence: 94%

“…The delay in filling out medical records causes when the patient has finished treatment, the medical record has not been filled out completely (33). On the other hand, filling out the initial medical assessment form, which is also part of the service process, will inevitably increase the waiting time, mainly if the doctor is not used to filling it out (12). At Puri Bunda Mother and Child Hospital, the organizational culture that filled out patient's initial medical assessment sheet during accreditation only affected the incompleteness of the form.…”

Section: Individual External Factorsmentioning

confidence: 99%

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Initial Assessment Form of Medical Record Document: Is It Important to Complete?

Zhafira Anisah Kesuma,

Nuthea,

Hariyanti

2022

JKB

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Medical record document completeness is crucial because it serves as a means of communication, quality evaluation, payment, and legal protection. A preliminary study showed that none of the initial assessment forms in the outpatient unit of Puri Bunda Mother and Child Hospital were filled completely. This study aimed to explore the causes of incomplete initial assessment forms to avoid lawsuits against the hospital. The method used was qualitative research with a case study approach. Data were collected using triangulation, which included in-depth interviews with 15 participants, flow observations, and document studies on 150 medical record files. Data were analyzed using thematic analysis. The document study found none of the medical records with a complete initial assessment form (0%). A total of 141 documents (94%) were not filled at all, and only 9 (6%) of the initial assessment forms were filled in certain fields. The flow observation disclosed that file availability was one of the contributing problems to the completeness of filling. Seven reasons for incomplete initial medical assessment documents were categorized into individual internal and external factors. The internal factors include the lack of awareness of doctors and feeling a high workload, and the external factors include the absence of communication between management and doctors, unavailability of work procedures, the absence of a reward and punishment system, the format and availability of initial assessment forms, and individual culture.

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Section: Discussionmentioning

confidence: 94%

Section: Individual External Factorsmentioning

confidence: 99%

Initial Assessment Form of Medical Record Document: Is It Important to Complete?

Zhafira Anisah Kesuma,

Nuthea,

Hariyanti

2022

JKB

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“…11 The outpatient medical assessment form at least includes the patient's medical history, primary complaint, allergy history, physical examination, diagnosis, and action plan. 12 Based on the Regulation of the Minister of Health of the Republic of Indonesia number 290/Menkes/PER/III/2008, informed consent is an agreement given to a patient or family who has received a complete and detailed explanation regarding the medical action. Informed Consent is closely related to law and ethics.…”

Section: Discussionmentioning

confidence: 99%

“…Arrangements in medical completion will provide legal protection. 12 Law of Republic Indonesia Number 29 /2004 concerning Medical Practice states that "Every medical or dental action that a doctor or dentist will carry out on a patient must receive approval". 14 Chapter 5 of the Indonesian Medical Ethics Code issued by the MKEK IDI doctor (Honorary Council of Medical Ethics of the Indonesian Doctors Association) states that "every act or advice that may weaken psychological or physical endurance must receive the consent of the patient/family and only given for the benefit of the patient and the wellbeing of the patient".…”

Section: Discussionmentioning

confidence: 99%

Analysis of Medical Record Document Filling Completeness of Outpatient at Nala Husada Dental Hospital

Indarti

Agustia

2022

IDJ

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Medical records (RM) as patient health information recorded assessment results, plans and implementation of care, treatment, integrated patient progress, as well as a summary of discharge for inpatients made by PPA. The results of medical record documents tracing at the Nala Husada dental hospital found that the RM was incomplete. This study aims to analyze the completeness of medical records filling that does not align with the accreditation standard of medical records management and health information (MRMIK). This study identified causal factors as a follow-up to implementing patient medical record management. It was conducted quantitatively with a descriptive observational approach. Data was obtained through observation, interviews, and documentation at the medical record unit during July 2022. The data was then processed and analyzed. Based on the analysis of the completeness of the 80 file documents, 86.25% were found to be complete, and 13.75% were incomplete. Incomplete medical record documents with good records were 17.4%, 16% important reports/records, 12.5% author authentication, and 8% patient identity. Factors causing incomplete filling of medical record documents with the management element approach included human error (lack of understanding and discipline, limited number of staff, training), Material and Machine (limited equipment, various documents, unspecific evaluation monitoring review), and method (incomplete regulatory studies), monitoring and evaluation are not continuous), and money (not included in the program budget plan). Recommendations to improve the completeness of medical record filling were training, sanctions, and rewards, regulation review, procedures for filling as per PPA requirements, and standardization of medical record forms.

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“…Asesmen awal medis merupakan hal wajib yang dilakukan sebelum pasien di rawat inap atau sebelum tindakan pada rawat jalan di rumah sakit, tidak boleh lebih dari 30 hari, atau riwayat medis telah diperbaharui dan pemeriksaan fisik telah diulangi (Kepmenkes RI, 2022). Masih adanya dokter yang mengatakan bahwa pemberian asesmen awal kepada pasien terkadang lupa dilakukan, dapat dipengaruhi oleh beberapa faktor, diantaranya banyaknya pasien yang datang, kurangnya SDM, dan terlewatnya atau ketidak telitian terhadap pengisian asesmen pasien (Safitri et al, 2022). Maka dari itu, untuk meningkatkan kepatuhan melengkapi asesmen perlu dilakukan evaluasi secara berkala dengan menggunakan checklist untuk menilai tingkat kepatuhan dokter dalam melengkapi asesmen sehingga perlu dilakukan sosialisasi.…”

Section: Metode Penelitianunclassified

Penilaian Kinerja Dokter RS Medika Utama Blitar Berdasarkan 6 Kompetensi Umum Dokter

Kirana,

Nugraheny

2023

JPKM

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Penilaian kinerja dokter merupakan faktor penting dalam rumah sakit karena menjadi acuan dalam memberikan pelayanan terbaik kepada masyarakat. Tujuan penelitian ini adalah untuk menilai kinerja dokter RS Medika Utama Kabupaten Blitar berdasarkan 6 Kompetensi Umum Dokter. Penelitian yang dilaksanakan pada Rabu, 29 Maret 2023 hingga Minggu, 2 April 2023 ini menggunakan jenis penelitian deskriptif dengan pendekatan cross sectional. Populasi pada penelitian ini adalah seluruh dokter baik Dokter Umum, Dokter Gigi dan Dokter Spesialis di Rumah Sakit Medika Utama Kabupaten Blitar yang berjumlah 30 dokter. Teknik pengambilan sampel dalam penelitian ini menggunakan Total Sampling. Instrumen penelitian menggunakan kuesioner berjumlah 11 pertanyaan, kemudian hasilnya akan dianalisis dengan teknik analisis data univariat. Hasil penelitian menunjukkan bahwa kinerja dokter di RS Medika Utama Blitar sudah dalam kategori baik. Namun, jika dilihat berdasarkan setiap aspek, masih ada beberapa kekurangan, yaitu terdapat 3,3% dokter menyatakan bahwa pengetahuan medis/klinis yang kurang, serta keterampilan interpersonal dan komunikasi baik terhadap tenaga medis lain maupun keluarga pasien yang masih kurang. Diadakannya pelatihan dan pendidikan yang memadai tentang etika dan praktik medis yang benar, serta mengenai keterampilan interpersonal dan komunikasi kepada dokter, diharapkan dapat meng-update ilmu para dokter terhadap ilmu medis/klinis terbaru dan memenuhi standar etika yang ditetapkan oleh rumah sakit.

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Tinjauan Kelengkapan Pengisian Formulir Assesment Awal Poli Klinik Pasien Rawat Jalan Menggunakan Metode IAR

Cited by 3 publications

References 3 publications

Initial Assessment Form of Medical Record Document: Is It Important to Complete?

Initial Assessment Form of Medical Record Document: Is It Important to Complete?

Analysis of Medical Record Document Filling Completeness of Outpatient at Nala Husada Dental Hospital

Penilaian Kinerja Dokter RS Medika Utama Blitar Berdasarkan 6 Kompetensi Umum Dokter

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