Analisis Penyelenggaraan Rekam Medis Rawat Inap Di Rumah Sakit Islam (RSI) Ibnu Sina Padang Tahun 2016

MIA, AUDIA AE (2016) Analisis Penyelenggaraan Rekam Medis Rawat Inap Di Rumah Sakit Islam (RSI) Ibnu Sina Padang Tahun 2016. Diploma thesis, Universitas Andalas.

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Abstract

UNIVERSITAS ANDALAS Skripsi, November 2016 MIA AUDIA A.E No. BP : 1210331010 ANALISIS PENYELENGGARAAN REKAM MEDIS RAWAT INAP DI RUMAH SAKIT ISLAM IBNU SINA PADANG TAHUN 2016 xii + 110 halaman, 14 tabel, 2 gambar, 23 lampiran ABSTRAK Tujuan Penyelenggaraan rekam medis rawat inap RSI Ibnu Sina Padang masih terdapat permasalahan baik dari keterlambatan pengembalian dokumen > 1x 24 jam, dan peningkatan ketidaklengkapan dokumen rekam medis pada 2 Triwulan sebanyak 2,04 % serta permasalahan akibatnya meningkatnya jumlah kunjungan pasien BPJS. Tujuan penelitian ini adalah mengetahui informasi penyelenggaraan rekam medis rawat inap di RSI Ibnu Sina Padang tahun 2016. Metode Jenis penelitian kualitatif dengan pendekatan sistem dari input, proses, dan output. Informan penelitian 15 orang, dengan teknik pengambilan sampel secara purposive sampling. Pengumpulan data dilakukan dengan cara wawancara mendalam, telaah dokumen dan observasi. Pengolahan data dilakukan dengan reduksi data, penyajian data dan penarikan kesimpulan dan analisa data dilakukan dengan triangulasi sumber dan metode. Hasil Hasil penelitian didapatkan tenaga rekam medis sudah mencukupi, namun permasalahannya pada pengorganisasian dan tanggung jawab tenaga yang ada. Dana rekam medis dari rumah sakit belum mencukupi sepenuhnya. Sudah ada SOP dalam penyelenggaraannya, namun belum berjalan sesuai yang diharapkan. Alat dan bahannya belum cukup memadai. Sarana dan prasarana belum memadai. Pendaftaran pasien terkendala data pasien yang tidak lengkap. Pengisian rekam medis belum lengkap dan jelas. Penataan rekam medis belum maksimal. Analisis dan pelaporan sudah berjalan, namun terkendala waktu dan tenaga dalam pembuataannya. Pengarsipan rekam medis sudah sesuai SOP. Kesimpulan Penyelenggaraan rekam medis rawat inap belum berjalan dengan baik yaitu dilihat dari input yang masih kurang memadai baik dana, metode, alat dan bahan, sarana parasarana, proses pada pengisian rekam medis belum lengkap dan outputnya keterlambatan penyerahan rekam medis. Disarankan untuk ketersediaan input lebih diptimalkan, terutama tempat penyimpanan, serta proses sesuai SOP, sehingga output tercapai. Daftar Pustaka : 30 (1997-2015) Kata Kunci : Analisis rekam medis, rawat inap FACULTY OF PUBLIC HEALTH ANDALAS UNIVERSITY Undergraduate Thesis, November 2016 MIA AUDIA A.E No. BP : 1210331010 THE ANALYSIS OF INPATIENT MEDICAL RECORD IMPLEMENTATION AT ISLAMIC HOSPITAL (RSI) IBNU SINA IN PADANG 2016 xii + 110 pages, 14 tables, 2 images, 23 attachments ABSTRACT Objective Implementation of inpatient medical records RSI Ibn Sina Padang is still a problem either late return of documents> 1x 24 hours, and an increase in incomplete medical record documents on 2nd Quarter of as much as 2.04% and as a result problems BPJS increasing number of patient visits. The purpose of this study was to determine the organization of information inpatient medical records in RSI Ibn Sina Padang in 2016. Method This type of research is a qualitative research approach of systems of input, process and output. The informants of 15, with a sampling technique is purposive sampling. The data collection was done by in-depth interviews, a document review and observations. Data processing was performed with data reduction, data presentation and conclusion and data analysis was done by triangulation of sources and methods. Result Results obtained medical records personnel are sufficient, but the problem is in the organization and responsibilities of existing personnel. Fund medical records from the hospital entirely inadequate. Already there SOP in its implementation, but has not run as expected. The tool and the material has not been sufficient. Inadequate facilities and infrastructure. Patient enrollment constrained patient data is incomplete. Charging medical record is incomplete and unclear. Structuring the medical record is not maximized. Analysis and reporting is already running, but is constrained time and energy in pembuataannya. Archiving medical records was appropriate SOP. Conclusion Implementation of inpatient medical records have not been going well, namely in terms of input that is still lacking both funds, methods, tools and materials, the means parasarana, the charging process is not yet complete medical record and output delay in delivery of medical records. It is advisable to over-optimized availability of inputs, especially storage, as well as the process according to SOP, so the output is reached. References : 30 (1997-2015) Keywords : Analysis of medical records, inpatient

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