ANALISIS KELENGKAPAN PENGISIAN FORMULIR INFORMED CONSENT TINDAKAN OPEN REDUCTION INTERNAL FIXATION (ORIF)

Abstract

Abstract
Based on the pre survey in the Muhammadiyah hospital of Selogiri Wonogiri, the form filling of Informed Consent in
the ORIF treatment reached 10 forms, and 6 incomplete forms. The completion of Informed Consent form filling had
not achieved the minimum service standard of the hospital. The purpose of this research is to analyze the completion of
Informed Consent form filling with ORIF treatment in the Muhammadiyah hospital of Selogiri Wonogiri in 2014. This
research is descriptive research through retrospective approach. The research variable was 4 quantitative analysis reviews,
namely patient identification review, important report review, authentication review, and correct documentation
review. The population and the sample were the whole Informed Consent forms with ORIF treatment which was 45
forms. The research instrument was checklist. The data were collected through observation and unstructured interview.
The data were analyzed through collecting, editing, classification, tabulating, and narrating. The data analysis used was
descriptive analysis. The analysis of patient identification completion, name item is 45 (100%), gender completion is 8
(17.78%). Important report completion, date and time item are 40 988.89%), the item of type and content information
incompletion is 38 (84.44%). The completion of patients’ name authentication is 45 (100%), the incompletion of doctor’s
signature item is 31 968.895). The completion of correct documentation item, clear and legible record is 45 (100%), the
incompletion of fixed line item is 32 (71.11%). It can be concluded that the Informed Consent form filling with ORIF
treatment in the Muhammadiyah hospital of Selogiri Wonogiri in 2014 is known that the highest incompletion in the
important report is 84.445 in the item of content and type of information, so it needs coordination between associate
nurses and doctors who is responsible to the patients in order to remind the doctors to write the information given to the
patients.
Key Words : Completion, ORIF
Abstrak
Berdasarkan hasil survey pendahuluan di Rumah Sakit Muhammadiyah Selogiri Wonogiri, Dalam pengisian formulir
Informed Consent pada tindakan ORIF (Open Reduction Internal Fixation) sebanyak 10 formulir, terdapat 6 formulir tidak
lengkap. Kelengkapan pengisian formulir informed consent masih belum mencapai Standar Pelayanan Minimal Rumah
Sakit. Tujuan penelitian ini adalah menganalisis kelengkapan pengisian formulir Informed Consent tindakan ORIF
(Open Reduction Internal Fixation) di Rumah Sakit Muhammadiyah Selogiri Wonogiri tahun 2014. Jenis penelitian adalah
deskriptif. Metode pendekatan adalah retrospektif. Variabel penelitian ini adalah 4 Review analisis kuantitatif yaitu
review identifikasi pasien, review pelaporan yang penting, review otentikasi dan review pendokumentasian yang benar.
Populasi dan sampel penelitian adalah semua formulir informed consent tindakan orif sejumlah 45 formulir. Instrumen
penelitian adalah check list. Cara pengumpulan data adalah observasi dan wawancara tidak terstruktur. Subjek penelitian
adalah petugas rekam medis bagian Assembling dan objek penelitian adalah Formulir informed consent tindakan Open
Redution Internal Fixation (ORIF) di Rumah Sakit Muhammadiyah Selogiri Wonogiri tahun 2014. Teknik pengolahan
yaitu Pengumpulan (Collecting), Edit (Editing), Klasifikasi (Classification), Tabulasi (Tabulating), Memaparkan
(Narasi). Analisis data yang digunakan adalah data deskriptif. Analisis kelengkapan identifikasi pasien ,item nama 45
(100%), ketidaklengkapan item jenis kelamin 8 (17,78%). Kelengkapan pelaporan yang penting, item jam dan tanggal
40 (88,89%), ketidaklengkapan item jenis dan isi informasi 38 (84,44%). Kelengkapan autentikasi item nama pasien 45
(100%), ketidaklengkapan item Tanda Tangan Dokter 31 (68,89%). Kelengkapan item pendokumentasian yang benar
item pencatatan jelas dan terbaca 45 (100%), ketidaklengkapan item penggunaan garis tetap item 32 (71,11%). Saran
dari penelitian ini adalah perlu adanya kerjasama antara dokter dan petugas assembling dalam melengkapi formulir
informed consent.
Kata Kunci : Kelengkapan, ORIF