Perpustakaan Terpadu

ABSTRAK Prihatiningrum, Nurul. 2018. “Implementasi Buku Petunjuk Teknis Pengisian Formulir Rekam Medis terhadap Pemahaman Petugas dan Kelengkapan Dokumen Rekam Medis di Puskesmas Rampal Celaket”. Laporan Tugas Akhir. D-III Perekam Medis dan Informasi Kesehatan. Pembimbing: Diniyah Kholidah, SST., S.Gz., MPH. Rekam medis mencakup informasi yang dapat digunakan sebagai acuan apabila pasien datang kembali ke pelayanan kesehatan untuk berobat ulang. Perlu adanya kelengkapan dalam pengisian tiap formulir pada rekam medis pasien agar tujuan dari adanya rekam medis tercapai. Di Puskesmas Rampal Celaket belum terdapat Standart Operating Procedure (SOP) dan sosialisasi mengenai pengisian 31 formulir rekam medis yang digunakan. Penelitian ini bertujuan untuk mengetahui pemahaman petugas dan kelengkapan dokumen rekam medis dikaitkan implementasi buku petunjuk teknis pengisian formulir rekam medis di Puskesmas Rampal Celaket. Jenis penelitian ini cross sectional dengan rancangan penelitian pra-eksperimen One Group Pretest-Postest Design dan pendekatan kuantitatif. Instrumen penelitian menggunakan kuesioner dan checklist dengan sampel 20 petugas dan 96 kunjungan pasien serta diolah menggunakan uji statistik Paired-sample t-Test. Hasil uji statistik didapat nilai signifikansi 0,000 untuk pemahaman petugas dan nilai signifikansi 0,000 untuk kelengkapan dokumen rekam medis, artinya nilai signifikansi lebih kecil dari 0,05 sehingga H0 ditolak atau terdapat perbedaan pemahaman petugas dan kelengkapan dokumen rekam medis sebelum dan sesudah implementasi buku petunjuk teknis pengisian formulir rekam medis di Puskesmas Rampal Celaket. Implementasi buku petunjuk teknis pengisian formulir rekam medis dapat membantu meningkatkan pemahaman petugas dan persentase kelengkapan dokumen rekam medis agar dokumen rekam medis lengkap 100% dan menjadi panduan dalam pembuatan SOP pengisian tiap formulir rekam medis. Kata Kunci : Pemahaman Petugas, Kelengkapan Dokumen, Buku Petunjuk Teknis

ABSTRACT Prihatiningrum, Nurul. 2018. “Implementation of Technical Instruction Book of Filling Out of Medical Record Form to Understanding of Officers and Completeness of Medical Records Document at Rampal Celaket Public Health Center”. Final Report. D-III Medical Recorder and Health Information. Advisor: Diniyah Kholidah, SST., S.Gz., MPH. The medical records include information that can be used as a reference when patients return to health services for treatment. Requires completeness in filling out each form on the patient's medical records so that the purpose of the medical record is achieved. In Rampal Celaket Public Health Center, there is no Standard Operating Procedure (SOP) and socialization about the procedure of filling 31 medical record form that be used. This research aims to determine the understanding of officers and the completeness of medical records document related to the implementation of technical instruction book of filling out of medical record form at Rampal Celaket Public Health Center. This type of research is a cross sectional study with pre-experimental One Group Pretest- Postest Design and quantitative approach. The research instrument used questioner and checklist with sample of 20 officers and 96 patient visits and processed using Paired-sample T-Test statistic test. The statistical test results obtained the significance value of 0,000 for understanding of officers and the significance value of 0,000 for completeness of medical records document, meaning more significance value small from 0,05 so that H0 is rejected in other words there is a difference to the understanding of officers and the medical records document completeness before and after the implementation of technical instruction book of filling out of medical record form at Rampal Celaket Public Health Center. Implementation of technical instruction book of filling out of medical record form can help improve understanding of officers and percentage of medical records document completeness to complete 100% and guide in making SOP of filling each medical record form. Keywords: Understanding Officers, Document Completeness, Technical Instruction