ANALISIS KELENGKAPAN PENGISIAN LAPORAN OPERASI PASIEN BEDAH GUNA MENUNJANG MUTU REKAM MEDIS

Resti Pratiwi, Meira Hidayati, Aris Susanto

Abstract


This study aims to analyze completeness of the surgical patient report at the hospital X  Bandung. The research method is qualitative with a descriptive approach and the data collected by observation, interview with medical records officer, heads of medical records and doctors. The technique of collecting sampel used is Purposive Sampling based on Slovin formula. The object of the study was 80 sample of the surgical report. Based on result : patient review identification 100%, review vital repots 65%, review on authenticity 90%, and long review 78%. with any problems the have: operation loading sheet to be incomplete, the doctor’s writing cant read clearly, doctor’s did not provide important reports. The advice the writer gives to fix the problem, conduct a verification of the operation report sheet, return your surgical report sheet to be equipped by the doctor, give 1x24 hours to complete the operation report sheet

Keywords


Completeness, Operation report sheet & Quality of Medical Record.

Full Text:

PDF

References


Dirjen Yanmed tahun 2006.

Peraturan Menteri Kesehatan RI No. 269 tahun 2008.

UU No. 36 tahun 2009.

UU No. 29 tahun 2014.

Keputusan Menteri Kesehatan Nomor 129 tahun 2008 tentang Standar Pelayanan Minimal Rumah Sakit.

Surat edaran Dirjen Pelayanan Medik Tahun 1995 Nomor HK.00.06.1.5.01160 tentang Petunjuk Teknis Pengadaan Formulir Rekam Medis dan Pemusnahan Arsip Rekam Medis di Rumah Sakit.

Hardani. (2020). Metodologi Penelitian Kualitatif & Kuantitatif. Pustaka Ilmu: Yogyakarta.

Hatta, Gemala, R. (2014). Pedoman Manajemen Informasi Kesehatan di Sarana Pelayanan Kesehatan. Penerbit Universitas Indonesia: Jakarta.

Indradi, Rano. (2017). Rekam Medis. Universitas Terbuka. Tangerang Selatan.

Sugiono. (2019). Metode Penelitian Kuantitatif, Kualitatif dan R&D. Penerbit Alfabeta: Bandung.

Sukmadinata, Nana Syaodih. (2009). Metode Penelitian pendidikan. Bandung: Remaja Rosdakarya.




DOI: https://doi.org/10.33758/mbi.v16i8.1535

Refbacks

  • There are currently no refbacks.


____________________________________________
MEDIA BINA ILMIAH

ISSN 1978-3787 (print) | 2615-3505( online)
Published by BINA PATRIA | Email: laloemipa@gmail.com

Creative Commons License
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.

 

View My Stats