Gambaran Perbedaan Kelengkapan Isi Resume Medis Pasien Rawat Inap Sebelum Dan Saat Pandemi Covid-19 Di Rumah Sakit Umum Daerah Wangaya Denpasar
DOI:
https://doi.org/10.25078/jyk.v6i1.1854Keywords:
Incompleteness, Medical Resume, Pandemic, Covid-19Abstract
An incomplete medical resume is a very important issue because it can provide detailed information during the patient's stay in the hospital. This has an impact on the quality of medical records and services provided by hospitals. Related on the results of interviews and observations at Wangaya Hospital there are differences in filling medical resume before and during the pandemic. In this regard, the purpose of this study is to get an overview of the completeness of inpatients medical resume before and during the pandemic at the Wangaya General Hospital Denpasar. This study applied a descriptive analytic qualitative research design with cross sectional type. Number of medical record samples that were used before and during the pandemic were 22,160 by using total sampling. The results of the interviews and the the analysis stated that the sample data in research on medical records of inpatients before the 2019 pandemic, the inpatients was 13,644 while in 2021 the research sample data was 8,516 medical records of inpatients during the pandemic, the difference of incomplete review of identification with a difference of 12%, the review of important report with a difference of 14%, the review of authentication with a difference of 8%, and the documentation review with a difference of 1%. Several contributing factors include doctors, nurses and registrars who are still delaying the return of medical records for those who have not filled them out. Based on the results of the study, it can be concluded that there were differences in the completeness of medical resumes at Wangaya Denpasar Hospital before and during the Covid-19 pandemic.
References
Azwar, & Azrul. 1996. Prosedur Administrasi Kesehatan. Jakarta:Bina Aksara Rupa.
Departemen Kesehatan Republik Indonesia. 2008. Peraturan Menteri Kesehatan Nomor 269 tentang Rekam Medis. Jakarta, Indonesia.
Depkes RI. 2006. Pengelolaan Rekam Medis Rumah Sakit Di Indonesia Revisi II, Jakarta. Direktorat Jenderal Pelayanan Medik.
Gibson, I., & Donnelly, K. 2009. Organizational Behavior Thirteenth Edition. New York : McGraw Hill
Hatta, GR, 2008. Pedoman Manajemen Kesehatan di Sarana Pelayanan Rumah, Mutu Rekam Medis Hal 363. Jakarta: Universitas Indonesia.
Hatta, G. R. 2010. Pedoman Manajemen Informasi Kesehatan di Sarana Pelayanan Kesehatan. Jakarta: Penerbit Universitas Indonesia (UIPress)
Hatta, G. R. 2013. Pedoman Manajemen Informasi kesehatan di sarana Pelayanan Kesehatan Tentang Tujuan, Penggunaan dan Fungsi Rekam Medis. Jakarta: UI-Press.
Hatta, G. R. 2014. Pedoman Manajemen Informasi Kesehatan di Sarana Pelayanan Kesehatan, Identifikasi, Authentifikasi dan Laporan Penting, Jakarta: Penerbit Universitas Indonesia.
Hidayah, Aep Nurul. 2015. Tinjauan Kelengkapan Lembar Resume Medis Unit Rawat Inap.
Hakman, H., Suhadi, S., & Yuniar, N. 2021. Pengaruh Beban Kerja, Stres Kerja, Motivasi Kerja Terhadap Kinerja Perawat Pasien Covid-19. Nursing Care and Health Technology Journal NCHAT, 1(2), 47-54.
Joint Commission International. 2017. Joint Commission International Accreditation Standards for Hospitals. 6th ed. Illionis: Department of Publications Joint Commission Resources.
Kars S, Pada V, Manajemen S. 2016. 2017. Tinjauan Pelaksanaan Komite Akreditasi Rumah Sakit (KARS) versi 2012 Pada Standar Manajemen Komunikasi Informasi (MKI) 8 di RSU Sufina Azis Medan ;(1):200–6.
Menteri Kesehatan RI No.268/MenKes/ Per/XII/2007 tentang Rekam Medis. Jakarta : Departemen Kesehatan RI
Notoatmodjo, S. 2010, Metode Penelitian Pendidikan Kesehatan. Jakarta : Rineka Cipta.
Notoatmodjo, S. 2012. Metodologi Penelitian Kesehatan. Edisi Revisi. Jakarta: Rineka Cipta.
Nugraha, E. M., & Handayani, I. G. A. K. R. Kemenkes Nomor HK. 01.07/Menkes/382/2020 Sebagai Pembuka Jalan Perekonomian Indonesia Dalam Masa New Normal. In Seminar Nasional & Call for Papers
Riyantika Desy. 2018. Faktor-faktor ketidaklengkapan Pengisian Lembar Resume Medis Pasien Rawat Inap. Kediri : Jurnal Ilmiah
Sugiyono. 2012. Metode Penelitian Kuantitatif Dan Kualitatif Dan R&D. Bandung: Penerbit Alfabeta.
Sugiyono.2014. Metode Penelitian Pendidikan Pendekatan Kuantitatif, Kualitatif, dan R&D. Bandung: Alfabeta.
Shofari, Bambang, 2002. Modul Pembelajaran Sistem Rekam Medis Pelayanan Kesehatan, Semarang.
Tu, C., Crameri, G., Kong, X., Chen, J., Sun, Y., Yu, M., Xiang, H., Xia, X., Liu, S., & Ren, T. 2004. Antibodies To Sars Coronavirus In Civets. Emerging Infectious Diseases, 10(12), 2244.
Utomo, A.E.N. 2016 Faktor – Faktor yang Mempengaruhi Kelengkapan Resume Medis Pasien Rawat Inap di Rumah Sakit Umum. Dr.Seogiri Lamongan. Jawa Timur.
UU No 269/MenKes/Per/III/2008. Tentang Rekam Medis. Jakarta : Peraturan Mentri Kesehatan RI.
Undang-Undang Republik Indonesia. 2009. Undang-Undang Nomor 44 Tahun 2009 Tentang Rumah Sakit. Jakarta: Presiden RI.
Peraturan Mentri Kesehatan Republik Indonesia Nomor 269/Menkes/Per/III/2008 tentang Rekam Medis.
World Health Organization. 2010. International Statistical Classification of Diseases and Related Health Health Problems Volume 1 Tabular List (Tenth,Revision).
Wirajaya, M. K., & Nuraini, N. (2019). Faktor Faktor yang Mempengaruhi Ketidaklengkapan Rekam Medis Pasien pada Rumah Sakit di Indonesia. Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI), 7(2), 165.
