ANALISIS KELENGKAPAN RINGKASAN MASUK DAN KELUAR PASIEN RAWAT INAP TERHADAP MUTU REKAM MEDIS YANG DITINJAU DARI INDIKATOR KELENGKAPAN DI RUMAH SAKIT UMUM PREMAGANA GIANYAR - Si Ayu Sintya Dewi; Ni Made Diaris; Nyoman Ngurah Adisanjaya (Seminar Ilmiah Nasional Teknologi, Sains, dan Sosial Humaniora (SINTESA), 2020)
ABSTRAKBerdasarkan observasi pendahuluan di Rumah Sakit Umum Primagana Gianyar menunjukan kelengkapan pengisian lembar RMK sebanyak 61 formulir ringkasan masuk dan keluar bulan November 2019 yaitu terdapat ketidaklengkapan 55 (90,1%) dan lengkap 6 (9,9%). Tujuan penelitian yaitu mengetahui hubungan review identifikasi pasien, review autentifikasi, review laporan penting, dan review pendokumentasian yang benar terhadap indikator kelengkapan mutu rekam medis rekam medis di Rumah Sakit Umum Premagana Gianyar . Rancangan penelitian adalah deskripitif kuantitatif, jenis penelitian cross sectional (potong lintang). Jumlah sampel 64 formulir ringkasan masuk dan keluar pada bulan Maret-Mei 2020. Berdasarkan hasil riset, nilai kelengkapan terhadap review identifikasi (ρ value = 0,000<0,05), review autentifikasi (ρ value = 0,000<0,05), review laporan penting (ρ value = 0,000<0,05), review pendokumentasian (ρ value 0,490 >0,05). Ketidaklengkapan tertinggi terdapat pada laporan penting di item penilaian tindakan. Kesimpulan penelitian ini adalah review identifikasi pasien, review laporan penting, review autentifikasi berhubungan terhadap indikator kelengkapan mutu rekam medis di Rumah Sakit Umum Premagana Gianyar sedangkan review pendokumentasian tidak ada hubungan terhadap indikator kelengkapan mutu rekam medis di Rumah Sakit Umum Premagana Gianyar. Saran dari penelitian ini yaitu melakukan sosialisasi dan pembuatan prosedur kelengkapan ringkasan masuk dan keluar,Kata Kunci: Kelengkapan Rekam Medis, Mutu Rekam MedisABSTRACTBased on preliminary observations at the Primagana General Hospital, Gianyar shows that there are incompleteness for 55 (90,1%) forms and completeness for 6 (9,9%) forms of 61 summary forms for entry and exit of the RMK sheet in November 2019. The research objective was to determine the relationship between patient identification review, authentication review, important report review, and proper documentation review for indicators of completeness of medical records quality at Premagana General Hospital, Gianyar. The research design was a quantitative descriptive, cross-sectional research type (cross-sectional). The number of samples is 64 summary forms of entry and exit in March - May 2020. Based on the research results, the completeness value of the identification review is (ρ value = 0.000 <0.05), the authentication review is (ρ value = 0.000 <0.05), the report review important is (ρ value = 0.000 <0.05), review the documentation is (ρ value 0.490> 0.05). The highest incompleteness was found in important reports of action assessment items. This study concludes that review of patient identification, review of important reports and review of authentication relates to indicators of quality completeness of medical records at Premagana General Hospital, Gianyar. Meanwhile, documentation review has no relationship to indicators of quality completeness of medical records at Premagana General Hospital, Gianyar. Based on this research, it can be suggested that the hospital needs to do socialization and make procedures for completeness summary entry and exit.Keywords: Completeness of Medical Records, Quality of Medical Records