ANALISIS KUANTITATIF DOKUMEN REKAM MEDIS PASIEN RAWAT INAP DIAGNOSIS HEMATEMESIS MELENA

Abstract

ABSTRACT

 

Based on the preliminary survey conducted in Hospital Dr. Moewardi documents regarding medical records of hospitalized patients Hematemesis Melena diagnosis of 10 documents found incomplete medical record highs writing contained in document authentication by 5 medical records (50%). The research objective was to deter- mine the completeness of the document medical records of hospitalized patients in hospitals diagnosis Hemate- mesis Melena Dr. Moewardi fourth quarter of 2015.Type of research is descriptive with retrospective approach. The population is 46 documents. The sample size used 46 medical record documents were taken using saturated sample. Collecting data with unstructured interviews and observations, the instrument uses the checklist. Data processing techniques using the collecting, editing, tabulating, classification, data presentation. Analysis of the data used is descriptive analysis. Incomplete results showed that the highest percentage of patient identification based on age contained in the form of integrated development record as many as 16 documents of medical records (34.78%). Incomplete reporting the highest percentage required by the date and time contained in the medical management plan as much as 6 document medical records (13.04%). The highest incompleteness authentication based on the name and signature of the doctor / nurse highest percentage in the form of nutritional care early as

6 document medical records (13.04%). Incomplete documentation is correct based on the highest percentage of fixed lines are not filled in the form of nursing KSK medical assessment and summary return as much as 9 docu- ment medical records (19.56%). The conclusions of the study diagnosis Hematemesis Melena still incomplete, it is recommended that officers should fill out a form on a medical record documents in full, to the creation of good hospital care and quality.

 

Keywords: Quantitative Analysis, Hematemesis Melena

 

 

ABSTRAK

 

Berdasarkan survei pendahuluan yang dilakukan di RSUD Dr. Moewardi mengenai kelengkapan dokumen rekam medis pasien rawat inap diagnosis Hematemesis Melena dari 10 dokumen rekam medis ditemukan ketidakleng- kapan tertinggi penulisan terdapat pada autentikasi sebanyak 5 dokumen rekam medis (50%). Tujuan penelitian adalah untuk mengetahui kelengkapan pengisian dokumen rekam medis pasien rawat inap diagnosis Hematemesis Melena di RSUD Dr. Moewardi triwulan IV tahun 2015. Jenis penelitan yang digunakan adalah deskriptif dengan metode pendekatan retrospektif. Populasi yaitu 46 dokumen. Besar sampel yang digunakan 46 dokumen rekam medis yang diambil dengan teknik sampel jenuh. Cara pengumpulan data dengan wawancara tidak terstruktur dan observasi, instrumen menggunakan checklist. Teknik pengolahan data menggunakan collecting, editing, tabulat- ing, klasifikasi, penyajian data. Analisis data yang digunakan yaitu analisis deskriptif. Hasil penelitian menunjuk- kan bahwa Ketidaklengkapan identifikasi pasien persentase tertinggi berdasarkan umur terdapat pada formulir catatan perkembangan terintegrasi yaitu sebanyak 16 dokumen rekam medis (34,78%). Ketidaklengkapan pel- aporan yang dibutuhkan persentase tertinggi berdasarkan tanggal dan jam terdapat pada rencana penatalaksanaan medis sebanyak 6 dokumen rekam medis (13,04%). Ketidaklengkapan tertinggi autentikasi berdasarkan nama dan tanda tangan dokter/perawat persentase tertinggi pada formulir asuhan gizi awal sebanyak 6 dokumen rekam me- dis (13,04%). Ketidaklengkapan pendokumentasian yang benar berdasarkan garis tetap persentase tertinggi tidak terisi pada formulir assesment keperawatan ksk medical dan ringkasan pulang sebanyak 9 dokumen rekam medis (19,56%). Simpulan dari penelitian diagnosis Hematemesis Melena masih ada yang belum lengkap, maka disa-

 

rankan sebaiknya petugas mengisi lembar formulir pada dokumen rekam medis secara lengkap, agar terciptanya

pelayanan rumah sakit yang baik dan bermutu.

 

Kata kunci: Analisis Kuantitatif, Hematemesis Melena