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Jurnal Manajemen Informasi Kesehatan Indonesia
Article . 2014 . Peer-reviewed
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ANALISIS PENGISIAN FORMULIR RESUME MEDIS DIABETES MELLITUS PASIEN RAWAT INAP

Authors: Ratri Wulandari; Sri Sugiarsi;

ANALISIS PENGISIAN FORMULIR RESUME MEDIS DIABETES MELLITUS PASIEN RAWAT INAP

Abstract

Abstract Resume is a medical form that must be preserved. This sheet must be signed by the treating physician. Based on a preliminary survey in dr. Sayidiman Magetan, in Medical Resume form filling in patients with Diabetes Mellitus as much as 60% of the medical records of 67 documents found incomplete filling out the form on the patient’s state of the item and the name of the doctor. The purpose of this study is to analyze the charging Form Resume Medical Inpatient Diabetes Mellitus period fourth quarter of 2013 in the General Hospital dr. Sayidiman Magetan. This research is a descriptive retrospective approach. The population in this study is the overall medical resume form in patients with Diabetes Mellitus as many as 67 medical record documents. Sampling technique with saturated sampling techniques and sample documents used were 67 medical records of the total population. Research instrument was a checklist. Way of collecting data through observation and unstructured interviews. The results were obtained form filling medical resume (unfilled) diagnosis largest item that is present in 100% (67 documents) and form filling medical resume (not filled), the largest state of the items out there on the 62.68% (42 documents). State of the item not being filled out due to circumstances out of patients already written in summary form Round. The results of this study it can be concluded that the need to increase the rigor and discipline to the officer in charge of filling administrative data, clinical data and authentication, the need for cooperation between medical records personnel to other units, especially doctors and nurses in the medical record to complete the form. Keywords: Analysis, Charging Resume Medical Abstrak Resume medis merupakan formulir yang harus diabadikan. Lembar ini harus ditandatangani oleh dokter yang merawat. Berdasarkan survei pendahuluan di RSUD dr. Sayidiman Magetan, dalam pengisian formulir Resume Medis pada pasien Diabetes Mellitus sebanyak 60% dari 67 dokumen rekam medis ditemukan ketidaklengkapan pengisian formulir pada item keadaan keluar pasien dan nama dokter. Tujuan penelitian ini adalah menganalisis pengisian Formulir Resume Medis Diabetes Mellitus Pasien Rawat Inap periode Triwulan IV tahun 2013 di Rumah Sakit Umum Daerah dr. Sayidiman Magetan. Jenis penelitian ini adalah deskriptif dengan pendekatan retrospektif. Populasi dalam penelitian ini adalah keseluruhan formulir Resume Medis pada pasien Diabetes Mellitus yaitu sebanyak 67 dokumen rekam medis. Teknik pengambilan sampel dengan teknik sampling jenuh dan sampel yang digunakan adalah 67 dokumen rekam medis dari total populasi yang ada. Instrument penelitian adalah checklist. Cara pengumpulan data yaitu dengan observasi dan wawancara tidak terstruktur. Hasil penelitian diperoleh pengisian formulir Resume Medis (terisi) terbesar terdapat pada item diagnosis yaitu 100% (67 dokumen) dan pengisian formulir Resume Medis (tidak terisi) terbesar terdapat pada item keadaan keluar yaitu 62,68% (42 dokumen). Tidak terisinya item keadaan keluar dikarenakan keadaan keluar pasien sudah tertulis pada formulir Ringkasan Pulang. Hasil penelitian ini dapat disimpulkan bahwa perlu adanya peningkatan ketelitian dan kedisiplinan kepada petugas yang bertanggungjawab dalam pengisian data administratif, data klinis maupun otentikasi, perlu adanya kerjasama antara petugas rekam medis dengan unit lain khususnya dokter dan perawat dalam melengkapi formulir rekam medis. Kata Kunci: Analisis, Pengisian Resume Medis, Rawat Inap

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selected citations
These citations are derived from selected sources.
This is an alternative to the "Influence" indicator, which also reflects the overall/total impact of an article in the research community at large, based on the underlying citation network (diachronically).
BIP!Citations provided by BIP!
popularity
This indicator reflects the "current" impact/attention (the "hype") of an article in the research community at large, based on the underlying citation network.
BIP!Popularity provided by BIP!
influence
This indicator reflects the overall/total impact of an article in the research community at large, based on the underlying citation network (diachronically).
BIP!Influence provided by BIP!
impulse
This indicator reflects the initial momentum of an article directly after its publication, based on the underlying citation network.
BIP!Impulse provided by BIP!
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