PERAN AKREDITASI DALAM KELENGKAPAN PENGISIAN REKAM MEDIS DI KLINIK PRATAMA FIRDAUS
Abstract
Background: The incompleteness of medical record filling is a problem for
health care facilities.
Objective : To assess the role of accreditation in medical records
completeness at Firdaus Clinic
Methods: A retrospective study was performed to assess the role of
accreditation in medical records completeness at Firdaus Clinic. A total of
320 medical records registered during November2016-July2018. The
assessment based on Minister of Health Regulation
No.269/MENKES/PER/III/2008, education and monitor of drug side effects.
The result divided into initial phase after accreditation commitment (phase
1), preparation phase (phase 2), final phase (phase 3), and improvement
phase (phase 4). Each phase showed in 6 months, phase 4 in 3 months.
Result: There are 23% medical record complete proofed. The records filled
complete in date and time, identity, history and treatment. The lowest
percentage showed in vital sign, education and monitoring drug side effects.
In phase 2, there is a decrease on vital sign, physical examination and
education. In phase 3, there is an increase in physical examination and
education. In phase 4, there is an increase in vital sign and education.
Conclusion: Enhancement of health worker behavior to fulfill medical
record needs to be done continuously to improve the quality of performance.
Keywords: medical record, accreditation, phase