REPRESENTASI KUALITAS INFORMASI DOKUMEN REKAM MEDIS BERBASIS PERMENKES RI NOMOR 269/MENKES/PER/III/2008 DI KLINIK PRATAMA SURYA MEDIKA SEMARANG

Abstract

ABSTRAK

Salah satu komponen pelayanan kesehatan untuk menentukan mutu pelayanan kesehatan di fasilitas layanan kesehatan adalah tersedianya informasi dari rekam medis.  Kualitas informasi dokumen rekam medis ditentukan oleh beberapa hal diantaranya yaitu lengkap, akurat dan konsisten.  Penelitian ini bertujuan untuk mengetahui gambaran kualitas informasi dokumen rekam medis berbasis Permenkes RI No 269/Menkes/Per/III/2008 di klinik pratama surya medika semarang

Penelitan ini merupakan penelitian deskriptif dengan menggunakan desain penelitian crossectional. Lokasi pengampilan sampel di Klinik Pratama Surya Medika Semarang.  Populasi penelitian dokumen rekam  medis periode bulan Agustus-Desember 2019 dengan sampel penelitian sejumlah 200 dokumen rekam medis. Analisa data yang digunakan analisa univariat yang disajikan dalam bentuk distribusi frekuensi dan  prosentase dari kualitas informasi rekam medis pasien klinik surya medika semarang.  

Hasil observasi kualitas informasi dokumen rekam medis berdasarkan komponen kelengkapan didapatkan hasil terdapat ketidaklengkapan pada No Rekam Medis Pasien 55%, Tanggal Lahir 14%, Jenis Kelamin 9%, Alamat 36%, Tanggal Periksa 4%, Terapi 2% dan Tanda Tangan berikut Nama Dokter 95%. Berdasarkan komponen keakuratan didapatkan hasil adanya ketidakakuratan pada perbaikan no rekam medis pasien dengan cairan penghapus tulisan 1%, ketidaksesuaian no rekam medis pasien pada formulir dengan map 2% dan perbaikan tulisan (coretan) pada kolom diagnosis, anamnesis, terapi tidak diparaf nakes 14%.  Sementara untuk komponen konsistensi didapatkan hasil terdapat ketidakkonsistenan pada penulisan kode no rekam medis pasien tidak sesuai antara formulir dengan map 6% dan penulisan nama pasien tidak sesuai antara formulir dengan MAP 2%

Kualitas  informasi  dokumen rekam  medis berbasis Permenkes RI No 269 /Menkes/Per/III/2008 pada klinik pratama surya medika semarang masih didapatkan hasil kurang lengkap, kurang akurat dan kurang konsisten dengan besaran prosentase yang bervariasi  

Kata Kunci : Kualitas Informasi, Dokumen Rekam Medis, Permenkes RI No 269 /Menkes/Per/III/2008

ABSTRACT

One component of health service to determine the quality of health services in health care facilities is the availability of information from medical records. The quality of medical record document information is determined by several things including the complete, accurate and consistent. This Study aims to determine the quality of information on medical record documents based on the Minister of Health Republic of Indonesia Number 269/Menkes/Per/III/2008 at the Surya Medika Pratama clinic in Semarang

This research is a descriptive study using a cross-sectional research design. Location of the sample performance at Surya Medika Pratama Clinic Semarang. The population of the study was the medical record documents for the period August-December 2019 with a research sample of 200 medical record documents.  Analysis of the data used univariate analysis presented in the form of frequency distributions and percentages of the quality of medical record information of patients in the surya medika clinic in semarang

The results of observations of the quality of medical record document information based on the completeness component found that there was an incompleteness in the patient medical record number 55%, date of birth 14%, gender 9%, address 36%, check date 4%, therapy 2%, the following signatures is the name of the doctor 95%.  Based on the accuracy component, it is found that there is an inaccuracy in the improvement of the medical record number of patients with written eraser fluid 1%, Incompatibility of patient’s medical record number on the form with folder 2%, Improved writing (graffiti) in the diagnosis column, history taking, therapy not initialled by health workers 14%.  While for the consistency component, there was a result that there was an inconsistency in the writing of the patient’s medical record number which did not match the form with the map 16% and writing the patient’s name does not match the form with folder 2%

The quality of information on medical record documents based on the Republic of Indonesia Minister of Health Regulation Number 269/Menkes/Per/III/2008 in the Semarang Surya Pratama Clinic still results in incomplete, inaccurate and less consistent with varying percentages

Key words : Information Quality, Medical Record Documents, the Republic of Indonesia Minister of Health Regulation Number 269/Menkes/Per/III/2008