Perpustakaan Terpadu

ABSTRAK Candra Lukita, 2020. “Analisis Kelengkapan Dokumen Rekam Medis Rawat Jalan berdasarkan Kriteria Keakurasian Pendokumentasian Klinis di Puskesmas Dinoyo Kota Malang”. Laporan Tugas Akhir. Program Studi D-III Rekam Medis dan Informasi Kesehatan. Pembimbing Utama: Diniyah Kholidah, SST., S.Gz., MPH. Rekam Medis adalah berkas yang berisikan catatan dan dokumen tentang identitas pasien, pemeriksaan, pengobatan, tindakan dan pelayanan lain kepada pasien pada sarana pelayanan kesehatan. Kelengkapan dan keakuratan isi rekam medis berdampak pada mutu pelayanan kesehatan. Kriteria keakuratan untuk pendokumentasian klinis ada 7 (tujuh) dapat terbaca (legible), dapat dipercaya (reliable), tepat (precise), lengkap (complete), konsisten (consistent), jelas (clear) dan tepat waktu (timely). Tujuan penelitian ini adalah untuk mengetahui kelengkapan rekam medis rawat jalan berdasarkan kriteria pendokumentasian klinis yang akurat dan mengetahui faktor penyebab ketidaklengkapan pengisian dokumen rekam medis rawat jalan di Puskesmas Dinoyo Kota Malang. Populasi dalam penelitian ini sebanyak 660 rekam medis rawat jalan. Sampel dalam penelitian ini sebanyak 87 rekam medis rawat jalan. Jenis penelitian yang digunakan deskriptif kuantitatif. Pengumpulan data dilakukan dengan menggunakan lembar observasi checklist dan wawancara. Hasil penelitian ini menunjukkan bahwa prosentase kelengkapan yang memenuhi 7 (tujuh) kriteria pendokumentasian klinis pada review identifikasi sebanyak 90,5%, review pelaporan penting sebanyak 82,5%, review pencatatan sebanyak 83,5%, review autentifikasi sebanyak 84,3%. Faktor penyebab ketidaklengkapan pengisian dokumen rekam medis rawat jalan di Puskesmas Dinoyo Kota Malang adalah kurangnya sumber daya manusia. Saran dalam penelitian ini adalah kegiatan analisis kelengkapan dokumen rekam rekam medis dilakukan berdasarkan 7 (tujuh) kriteria pendokumentasian klinis agar terciptanya penyelenggaraan rekam medis yang berkualitas prima dan hasil analisis kelengkapan yang benar dan akurat. Kata Kunci : Kelengkapan dokumen rekam medis rawat jalan, tujuh kriteria

ABSTRACT Candra Lukita, 2020. “Analysis of Outpatient Medical Record Document Completeness based on Criteria of Clinical Documentation Accuracy at Dinoyo Public Health Center in Malang”. Final report. D-III Study Program Medical Record and Health Information. Main Advisor: Diniyah Kholidah, SST., S.Gz.,MPH. Medical Record is a file containing notes and documents regarding patient identity, examination, treatment, actions and other services to patients at health service facilities. The completeness and accuracy of the contents of medical records have an impact on the quality of health services. The accuracy criteria for clinical documentation are consist of 7 (seven) criteria, namely: legible, reliable, precise, complete, consistent, clear and timely. The purpose of this study was to determine the completeness of outpatient medical records based on accurate clinical documentation criteria and to determine the factors causing incompleteness in filling outpatient medical record documents at the Dinoyo Public Health Center in Malang. The population in this study was 660 outpatient medical records. The samples in this study were 87 outpatient medical records. The type of research used is descriptive quantitative. Data collection was carried out using observation checklist sheets and interviews. The results of this study indicate that the percentage of completeness that fulfills 7 (seven) clinical documentation criteria for identification review is 90.5%, important reporting review is 82.5%, recording review is 83.5%, authentication review is 84.3%. Factors causing incomplete filling outpatient medical record documents at the Dinoyo Community Health Center in Malang City is the lack of human resources. Suggestion in this research is the activity of completing medical record document analysis activities carried out based on 7 (seven) clinical documentation criteria so that the creation of a high quality medical record and the results of analysis of completeness is correct and accurate. Keywords : Completeness of outpatient medical record documents, seven criteria