Analisis Kuantitatif Rekam Medis Elektronik Pasien Rawat Jalan di Puskesmas Tambora
DOI:
https://doi.org/10.32585/jmiak.v7i2.5789Abstract
Puskesmas harus menjaga mutu pelayanan dengan menyediakan rekam
medis elektronik lengkap yang kualitasnya dijaga melalui analisis
kuantitatif. Penelitian ini bertujuan untuk mengetahui kelengkapan pengisian
rekam medis elektronik di Puskesmas Tambora dengan metode kuantitatif
deskriptif yang menggunakan sampel 99 rekam medis dari total 14.823
kunjungan rawat jalan bulan April 2024. Dari hasil penelitian yang
dilakukan oleh peneliti didapatkan informasi bahwa Puskesmas Tambora
sudah memiliki SOP tentang kelengkapan rekam medis elektronik yang
berjudul “SOP Penilaian Capaian Indikator Mutu Kelengkapan dan
Ketepatan Isi Rekam Medis”. Hasil analisis kuantitatif rekam medis
elektronik pasien rawat jalan di Puskesmas Tambora pada bulan April 2024
menunjukkan bahwa persentase kelengkapan mencapai 97,83%. Persentase
kelengkapan tertinggi terdapat pada komponen kelengkapan e-form yang
penting sebesar 99,83%, sedangkan persentase kelengkapan terendah
terdapat pada komponen pendokumentasian yang baik sebesar 95%. Saran
untuk penelitian ini yaitu petugas pendaftaran diharapkan lebih teliti dengan
menceklis kolom verifikasi untuk memastikan kelengkapan data. Selain itu,
sosialisasi kembali kepada PPA (Profesional Pemberi Asuhan) terkait
pentingnya kelengkapan rekam medis elektronik dan follow up secara rutin.
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