ANALISIS KELENGKAPAN PENGISIAN BERKAS REKAM MEDIS RAWAT JALAN DI PUSKESMAS SAMIGALUH 1 TAHUN 2020
DOI:
https://doi.org/10.32585/jmiak.v5i1.2189Abstract
Latar Belakang : Puskesmas bertanggung jawab untuk meningkatkan mutu pelayanan kesehatan kepada pasien. Mutu pelayanan kesehatan dapat dicapai dengan penilaian beberapa aspek, salah satunya adalah kualitas kelengkapan pengisian berkas rekam medis. Kelengkapan pengisian berkas rekam medis harus mencapai angka 100% selama 1x24 jam setelah pasien keluar. Berdasarkan hasil studi pendahuluan diperoleh informasi bahwa setiap dilakukan evaluasi masih banyak terdapat ketidaklengkapan isi berkas rekam medis di Puskesmas Samigaluh 1 maka penulis tertarik untuk melakukan identifikasi terkait kelengkapan pengisian pada formulir rawat jalan.
Tujuan : Mengetahui kelengkapan pengisian formulir rawat jalan di Puskesmas Samigaluh 1.
Metodologi : Untuk mengetahui persentase kelengkapan pengisian berkas rekam medis rawat jalan di Puskesmas Samigaluh 1 Tahun 2020 menggunakan metode penelitian deskriptif dengan pendekatan kuantitatif.
Hasil : Checklist kelengkapan identitas pasien lengkap 100%. Laporan penting kelengkapan data anamnesis sebesar 64%, data diagnosa dan tindakan mencapai 100%. Autentifikasi tanda tangan dokter yang terendah sebesar 60%, kelengkapan tertinggi yaitu pada data tanda tangan petugas rekam medis mencapai 100%, pengisian tanda tangan perawat 90% dan data jam/tgl kelengkapan pengisiannya mencapai 80%.
Kesimpulan : Kelengkapan identifikasi 100%. Kelengkapan pengisian laporan penting 64% data anamnesis yang terisi secara lengkap, diagnosa dan tindakan terisi 100% lengkap. Data autentifikasi penulisan nama dan tanda tangan dokter yang telah terisi lengkap sebanyak 60 rekam medis 60%, tanda tangan petugas rekam medis yang terisi dengan lengkap sebanyak 100 rekam medis 100%, tanda tangan perawat yang terisi dengan lengkap sebanyak 90%.
Kata kunci : Rekam medis, Identifikasi Kelengkapan, Rawat Jalan
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