Analisis Kualitatif Pendokumentasian Rekam Medis Kasus Cholecystectomy Di RS. Katolik St. Vincentius A Paulo Surabaya - IG JAROT BUDIHARJO (Indonesian Journal of Health Information Management, 2025)
Abstrak Menurut (Widjaja & Sugiarsi, 2023), analisis kualitatif merupakan bagian dari audit pendokumentasian Rekam Medis oleh Perekam Medis dan Informasi Kesehatan (PMIK), Pengertian analisis kualitatif suatu review pengisian Rekam Medis (RM) yang berkaitan dengan ketidakkonsistensian dan ketidaklengkapan sehingga menunjukkan bukti bahwa rekam medis tersebut tidak akurat dan tidak lengkap. Dari hasil survei awal analisis kualitatif pendokumentasian rekam medis kasus Cholecystectomy ditemukan kekonsistensian praktek pencatatan terkait keterbacaan dan kebermaknaan pendokumentasian rekam medis 61 % tidak konsisten. Tujuan penelitian adalah untuk mengetahui kekonsistensian pendokumentasian Rekam Medis rawat inap kasus Cholecystectomy berdasarkan analisis kualitatif di RS. Katolik St. Vincentius a Paulo Surabaya. Rancangan penelitian ini adalah deskriptif dimana penelitian ini ingin medeskripsikan atau memberi gambaran terhadap analisis kualitatif kekonsistensian pendokumentasian rekam medis kasus Cholecystectomy di RS. Katolik St. Vincentius a Paulo Surabaya. Jumlah populasi adalah seluruh dokumen rekam medis pasien rawat inap kasus Cholecystectomy periode bulan Juli - September tahun 2023 sejumlah 30 Dokumen Rekam Medis. Instrumen pengumpulan data yang digunakan dengan lembar Checklist. Hasil penelitian ini adalah kekonsistensian diagnosis dan tindakan 53,33% konsisten. Kekonsistensian pencatatan klinis 43,33% konsisten. Kekonsistensian penjelasan dan konfirmasi pengobatan yang dilakukan 46,66% konsisten. Kekonsistensian pencatataan Surat Persetujuan/ Penolakan Tindakan Kedokteran (SPTK) 70% konsisten. Kekonsistensian praktik pendokumentasian rekam medis 3,33% konsisten. Tidak ada hal-hal yang berpotensi tuntutan/ kompensasi ganti rugi. Sebaiknya dilakukan sosialisasi ulang terkait praktik pendokumentasian kepada para dokter terkait penulisan waktu pendokumentasian. Kata kunci: Kekonsistensian, Pendokumentasian, Kelengkapan, Cholecystectomy. Abstract According to (Widjaja & Sugiarsi, 2023), qualitative analysis is part of the audit of medical records documentation by Medical Recorders and Health Information (PMIK), the definition of qualitational analysis is a medical record filling review (RM) that relates to inconsistencies and incompleteness so that it shows evidence that the medical records are inaccurate and incompletely. From the results of the initial qualitative analysis of the medical record documentation of the Cholecystectomy case, the inconsistency of recording practices relating to readability and validity of medical records documentation was found to be 61% inconsistent. The aim of the research is to find out the consistency of the documentation of the medical records of hospitalized cases of Cholecystectomy based on qualitative analysis at the Catholic Hospital of St. Vincentius a Paulo Surabaya. The draft research is descriptive where this study wants to co-describe or give an overview of the qualitative analysis of the consistency of documentation of medical records of Cholecystectomy cases at the Catholic Hospital St. Vincentius a Paulo Surabaya. The population number is the entire medical record of patients in hospitalized cases of Cholecystectomy from July to September 2023 total of 30 medical records. The data collection tool used with the Checklist sheet. The results of this study are a consistency of diagnosis and action of 53.33% consistent. Consistency in clinical recordings of 43.33%. Consistencies in explanation and confirmation of treatment carried out 46.66% consecutive. Consistance in the recording of letter of consent/ rejection of medical action (SPTK) 70% consistent. Consistence in the practice of documentation of medical records of 3.33%. There are no potential claims for damages. It would be better to re-socialize the doctors' documentation practices in connection with the writing of the documentation time. Keywords: Consistency, Documentation, Equipment, Cholecystectomy