Gambaran Kelengkapan Pengisian Dokumen Resume Medis Pasien Rawat Inap di Puskesmas
DOI:
https://doi.org/10.32585/jmiak.v9i1.8175Abstract
Kelengkapan dokumen rekam medis yaitu hal yang sangat penting untuk dilakukan pelayanan atau prosedur medis kepada pasien dan akan selesai dalam waktu kurang dari 1 x 24 jam. Kelengkapan rekam medis harus mencapai 100%. Tujuan: Mengetahui review identifikasi, review laporan penting, review autentifikasi, review catatan yang baik kelengkapan pengisian resume medis pasien rawat inap di puskesmas. Metode: Deskriptif Kuantitatif, populasi 90 formulir dengan sampel 90 formulir, teknik total sampling dan pengumpulan data observasi dengan checklist dan wawancara. Hasil: 90 sampel didapatkan hasil review identifikasi 55 formulir (61,1%) lengkap dan 35 formulir (38,9%) tidak lengkap, laporan penting 12 formulir (13,3%) lengkap dan 78 formulir (86,7%) tidak lengkap, autentifikasi 19 formulir (21,1% lengkap dan 71 formulir (78,9%) tidak lengkap, catatan yang baik 65 formulir (72,2%) lengkap dan 25 formulir (27,8%) tidak lengkap. faktor ketidaklengkapan yaitu lupa dalam pengisian identitas, dan pekerjaan banyak. Saran: kebijakan kelengkapan pengisian DRM segera dibuat, memberikan tanda (-) pada item yang tidak perlu diisi, mengadakan sosialisasi tentang pentingnya kelengkapan pengisian resume medis, menyiapkan label identitas, mendesain formulir.
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