| dc.contributor.author | NURUL SETYAWATI, RENATA | |
| dc.date.accessioned | 2018-10-18T07:21:11Z | |
| dc.date.available | 2018-10-18T07:21:11Z | |
| dc.date.issued | 2018 | |
| dc.identifier.uri | http://repository.umy.ac.id/handle/123456789/22301 | |
| dc.description | Latar belakang : Ketidaklengkapan pengisian rekam medis menjadi masalah
yang dihadapi beberapa fasilitas pelayanan kesehatan.
Metode Penelitian : Desain penelitian adalah deskriptif retrospektif. Data
diambil dari 180 sampel rekam medis elektronik pelayanan dokter umum dan
140 sampel pada pelayanan dokter gigi. Penilaian kelengkapan berdasarkan
Permenkes No. 269/MENKES/PER/III/2008 ditambah edukasi dan
monitoring efek samping obat (MESO). Hasil data terbagi menjadi fase awal
setelah komitmen akreditasi, fase persiapan, fase akhir menjelang
pengumpulan dokumen, dan fase perbaikan menunggu dalam bentuk
persentase.
Hasil : Hasil penelitian menunjukkan terdapat 23% rekam medis yang terisi
lengkap. Secara umum, pada bagian tanggal dan waktu, identitas, anamnesis
dan terapi terisi lengkap Persentase terendah terdapat pada vital sign, edukasi
dan meso. Penurunan pada bagian vital sign, pemeriksaan fisik dan edukasi
terjadi pada fase persiapan. Pada fase akhir menjelang pengumpulan
dokumen terdapat peningkatan pada pemeriksaan fisik dan edukasi. Pada fase
perbaikan tedapat peningkatan pada vital sign dan edukasi.
Kesimpulan : Perbaikan perilaku tenaga kesehatan dalam kelengkapan
rekam medis perlu dilakukan melalui peningkatan mutu berkelanjutan untuk
mencapai target yang diharapkan.
Keyword : rekam medis, akreditasi, fase | en_US |
| dc.description.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 | en_US |
| dc.language.iso | other | en_US |
| dc.publisher | MMR UMY | en_US |
| dc.subject | medical record | en_US |
| dc.subject | accreditation | en_US |
| dc.subject | phase | en_US |
| dc.title | PERAN AKREDITASI DALAM KELENGKAPAN PENGISIAN REKAM MEDIS DI KLINIK PRATAMA FIRDAUS | en_US |
| dc.type | Thesis | en_US |
