STUDI DESKRIPTIF KELENGKAPAN PENGISIAN RESUME MEDIS RAWAT INAP
DOI:
https://doi.org/10.32585/jmiak.v6i2.3605Keywords:
Review, Kuantitatif, Resume MedisAbstract
Resume medis merupakan ringkasan seluruh pengobatan pasien dan merupakan salah satu instrumen penilaian akeditasi rumah sakit versi 2022 yaitu standar AKP 5.1 yang menyatakan bahwa ringkasan pasien pulang dibuat untuk semua pasien rawat inap yang keluar dari rumah sakit. Resume medis pasien harus diisi dengan lengkap karena ketidaklengkapan resume medis akan berdampak pada hasil akreditasi dan hasil evaluasi terhadap pelayanan yang telah diberikan selama perawatan . Tujuan penelitian adalah menganalisis kelengkapan pengisian resume medis rawat inap. Jenis penelitian adalah deskriptif kuantitatif. Populasi penelitian adalah resume medis pada dokumen rekam medis rawat inap di filling. Teknik pengambilan sampel yaitu Random Sampling. Besar sampel dihitung menggunakan rumus slovin dengan tingkat kesalahan 10%, didapatkan 100 sampel. Metode pengumpulan data yaitu observasi menggunakan checklist. Hasil penelitian menunjukkan bahwa pengisian review identitas pasien sebagian besar tidak terisi dengan lengkap (92%). Review laporan penting keseluruhan tidak terisi dengan lengkap (100%). Review autentikasi sebagian besar tidak terisi dengan lengkap (58%). Review pendokumentasian yang benar keseluruhan item tidak terisi dengan lengkap (100%). Kesimpulannya adalah analisis pengisian formulir resume medis rawat inap keseluruhan tidak lengkap 100%.
Kata kunci: Review, Kuantitatif, Resume Medis
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- 2023-11-30 (2)
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