Analisis Kuantitatif Dokumen Rekam Medis Rawat Inap di Rumah Sakit Ibnu Sina Kabupaten Gresik
Abstract
Medical records are data for compiling health information for both outpatient and inpatient visits. Based on the Minister of Health's decision number 129 of 2008 concerning minimum hospital service standards, recording medical record documents must be 100% complete and correct. The aim of this research is to analyze the incompleteness of inpatient medical records at Ibnu Sina Hospital, Gresik Regency based on 4 aspects, namely, the social data identification aspect, the important report aspect, the authentication aspect, and the correct documentation aspect. The population in this study is the number of inpatient medical record documents that have been deposited for the period June and July 2023, amounting to 1400 sample files obtained using random sampling techniques. Determining the sample size using the Slovin formula resulted in 100 medical record documents. This research is descriptive quantitative research. Based on the results of the analysis, identification reviews were on average complete 51%, incomplete 49%, reviews of important reports were on average complete 82.83%, incomplete 61%, authentication reviews were on average complete 66%, incomplete 34%, and On average, the correct documentation review was 61% complete, 31% incomplete. There needs to be outreach about the importance of patient identification to registration officers and all patient care providers. As well as the formation of a medical records committee and activeness of the room in monitoring the completeness of medical records
Keywords: Authentication review, correct documentation review, identification review, important report review
References
Ariffin, M., & Rudi, A. (2019). Analisis Kuantitatif Dokumen Rekam Medis Di Puskesmas Kebong. JUPERMIK (Jurnal Perekam Medis Dan Informasi Kesehatan), 2(2), 42–49.
Basyarudin, B. (2022). Aspek Yuridis Rekam Medis Elektronik Dijadikan Alat Bukti Apabila Terjadi Kesalahan Pelayanan Kesehatan. Jurnal Cakrawala Ilmiah, 1(12), 3495–3510. https://www.bajangjournal.com/index.php/JCI/article/view/3212
Berutu, C. A. N., Yanti Agustina, & Batubara, S. A. (2020). Kekuatan Hukum Pembuktian Rekam Medis Konvesional Dan Elektronik Berdasarkan Hukum Positif Indonesia. Jurnal Hukum Samudra Keadilan, 15(2), 305–317. https://doi.org/10.33059/jhsk.v15i2.2686
Devhy, N. L. P., & Widana, A. A. G. O. (2019). Analisis Kelengkapan Rekam Medis Rawat Inap Rumah Sakit Ganesha Di Kota Gianyar Tahun 2019. Jurnal Rekam Medis Dan Informasi Kesehatan, 2(2), 106. https://doi.org/10.31983/jrmik.v2i2.5353
Gustiara, B., Dewi, D. R., & Fannya, P. (2022). Analisis Kelengkapan Rekam Medis Rawat Inap Di Rumah Sakit Bhakti Mulia Tahun 2022. 3, 559–569.
Hikmah, F., Wijayanti, R. A., & Hidayah, N. (2018). Analisis Kualitatif Dokumen Rekam Medis Rawat Inap Diare Akut Balita Di Rumahsakitislammasyithoh Bangil Kabupaten Pasuruan Tahun 2016. Jurnal Manajemen Informasi Kesehatan Indonesia, 6(2), 104. https://doi.org/10.33560/.v6i2.194
Insani, T. H. N., & Wikansari, N. (2021). Evaluasi Pelaksanaan Identifikasi Pasien di Klinik Laras Hati Yogyakarta. JHeS (Journal of Health Studies), 5(1), 81–87. https://doi.org/10.31101/jhes.763
Khoiroh, A. N., Nuraini, N., & Santi, M. W. (2020). Faktor Penyebab Ketidaklengkapan Rekam Medis Rawat Inap di RSUD dr. Saiful Anwar Malang. J-REMI?: Jurnal Rekam Medik Dan Informasi Kesehatan, 2(1), 91–98. https://doi.org/10.25047/j-remi.v2i1.2080
Lesmana, J., & Suciana, D. (2022). Analisis Kuantitatif Kelengkapan Dokumen Rekam Medis Pasien Rawat Jalan di Puskesmas Cakranegara Tahun 2021. Nusadaya Journal of Multidiciplinary Studies, 1(1), 16–22.
Mahendra, 2018. (2019). Analisis Pelaksanaan Rekam Medis Pasien Rawat Inap di Rumah Sakit Umum Daerah dr. Rasidin Padang Tahun 2018. Fakultas Kesehatan Masyarakat Universitas Andalas. Padang, 1–146.
Maimun, & Sari, I. (2022). Analisis Deskriptif Kelengkapan Dokumen Rekam Medis Di Poli Rawat Jalan Kia Rsupn Dr. Cipto Mangunkusumo. Jurnal Kesehatan, 10(1), 13–24. https://doi.org/10.35913/jk.v10i1.244
Murtiningtyas, R. A., & Dhamanti, I. (2022). Analisis Implementasi Identifikasi Pasien di Rumah Sakit Untuk Meningkatkan Keselamatan Pasien di Indonesia. Media Gizi Kesmas, 11(1), 313–317. https://doi.org/10.20473/mgk.v11i1.2022.313-317
Rika, S., Nisa’, K., Wulandari, I., & Pramono, A. (2021). Analisis Kuantitatif Dokumen Rekam Medis Pasien Rawat Jalan di Puskesmas Gondanglegi. Health Care Media, 5(2), 88–95. https://stikeswch-malang.e-journal.id/Health/article/view/178
Riyantika, D. (2018). Analisis Faktor-Faktor Penyebab Ketidaklengkapan Pengisian Lembar Resume Medis Pasien Rawat Inap. Strada Jurnal Ilmiah Kesehatan, 7(1), 69–73. https://doi.org/10.30994/sjik.v7i1.153
Sinta, N. S. (2023). Analisis kuantitatif ketidak lengkapan pengisian berkas rekam medis pasien di puskesmas wolio kota baubau. 4(43), 2289–2296.
Supriyatin, U. (2018). Aspek Hukum Dalam Penyelenggaraan Praktik Kedokteran Dihubungkan Dengan Undang-Undang Nomor 29 Tahun 2004 Tentang Praktik Kedokteran. Jurnal Ilmiah Galuh Justisi, 6(1), 117. https://doi.org/10.25157/jigj.v6i1.1245
Swari, S. J., Alfiansyah, G., Wijayanti, R. A., & Kurniawati, R. D. (2019). Analisis Kelengkapan Pengisian Berkas Rekam Medis Pasien Rawat Inap RSUP Dr. Kariadi Semarang. ARTERI?: Jurnal Ilmu Kesehatan, 1(1), 50–56. https://doi.org/10.37148/arteri.v1i1.20
Wirajaya, M. K., & Nuraini, N. (2019). Faktor Faktor yang Mempengaruhi Ketidaklengkapan Rekam Medis Pasien pada Rumah Sakit di Indonesia. Jurnal Manajemen Informasi Kesehatan Indonesia, 7(2), 165. https://doi.org/10.33560/jmiki.v7i2.225
Yusuf Setiawan, M., Widjaja, L., Nurmalasari, M., Studi Manajemen Informasi Kesehatan, P., & Ilmu-Ilmu Kesehatan, F. (2020). Analisis Perbandingan Kelengkapan Rekam Medis Berdasarkan Metode Analisis Kuantitatif dengan Analisis Closed Medical Record Review di Rumah Sakit Kanker “Dharmais.” Health Information Management Journal ISSN, 8(1), 2655–9129.
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.