Pengelolaan rekam medis rawat inap di rumah sakit Haji Jakarta = In-patient medical record management in Jakarta Pilgrim's Hospital
| Main Authors: | Saraswanto Setyawan, author, Add author: Budi Utomo, supervisor, Add author: Ronnie Rivany, examiner, Add author: Amila Megraini, examiner, Add author: Ahmad Husni, examiner, Add author: Widyawati, examiner |
|---|---|
| Format: | Masters Bachelors |
| Terbitan: |
Fakultas Kesehatan Masyarakat Universitas Indonesia
, 2001
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| Subjects: | |
| Online Access: |
http://lontar.ui.ac.id/detail?id=72622 |
| ctrlnum |
72622 |
|---|---|
| fullrecord |
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<dc schemaLocation="http://www.openarchives.org/OAI/2.0/oai_dc/ http://www.openarchives.org/OAI/2.0/oai_dc.xsd"><type>Thesis:Masters</type><title>Pengelolaan rekam medis rawat inap di rumah sakit Haji Jakarta = In-patient medical record management in Jakarta Pilgrim's Hospital</title><creator>Saraswanto Setyawan, author</creator><creator>Add author: Budi Utomo, supervisor</creator><creator>Add author: Ronnie Rivany, examiner</creator><creator>Add author: Amila Megraini, examiner</creator><creator>Add author: Ahmad Husni, examiner</creator><creator>Add author: Widyawati, examiner</creator><publisher>Fakultas Kesehatan Masyarakat Universitas Indonesia</publisher><date>2001</date><subject>Medical records</subject><description>Tujuan pengelolaan Rekam Medis di rumah sakit adalah untuk menunjang tercapainya tertib administrasi dalam rangka upaya mencapai tujuan rumah sakit, yaitu peningkatan mutu pelayanan kesehatan di rumah sakit, oleh sebab itu dalam mengelola Rekam Medis, setiap rumah sakit harus selalu mengacu kepada pedoman/petunjuk teknis pengelolaan Rekam Medis yang dibuat oleh rumah sakit yang bersangkutan.
Pedoman/petunjuk teknis pengelolaan Rekam Medis pada suatu rumah sakit pada dasamya mengatur proses kegiatan yang dimulai pada saat diterimanya pasien di tempat penerimaan pasien, pencatatan data medis pasien selama pasien tersebut mendapatkan pelayanan medis, sampai pada penanganan berkas Rekam Medis pasien yang meliputi kegiatan penyimpanan serta pengeluaran berkas dari tempat penyimpanan untuk melayani perrnintaan/peminjaman bila pasien berobat ulang atau keperluan lain.
Dalam hal pengelolaan Rekam Medis, pencatatan data medis dalam berkas Rekam Medis pasien selama pasien tersebut mendapatkan pelayanan medis sampai pada pengembalian berkas Rekam Medik tersebut dari ruangan rawat inap, rawat jalan, maupun rawat darurat merupakan salah satu hal penting yang telah diatur di dalam pedoman pengelolaan Rekam Medik di Rumah Sakit Haji Jakarta.
Untuk rawat inap, pengembalian berkas Rekam Medis yang telah diisi dengan lengkap dan benar ke Sub Unit Rekam Medis adalah 2x24 jam setelah pasien keluar rumah sakit, sedangkan untuk rawat jalan dan rawat darurat, pengembalian berkas Rekam Medis setelah usai pelayanan atau shift tugas. Khusus untuk pengembalian berkas Rekam Medis rawat inap, hal ini perlu lebih diperhatikan, karena masalah yang akan dihadapi oleh rumah sakit akan lebih banyak dan lebih kompleks akibatnya, balk itu dari segi Mediko-Legal maupun tagihan dari pihak ketiga yang harus disertai resume medis.
Berdasarkan wawancara pra penelitian dengan Kepala Sub Unit Rekam Medis, seorang staf pada Sub Unit Rekam Medik, Kepala Unit Rawat inap dan beberapa perawat, serta pengamatan yang dilakukan di beberapa ruangan rawat imp Rumah Sakit Haji Jakarta selama bulan November tahun 2000, terdapat cukup banyak berkas Rekam Medik yang dikembalikan terlambat, akibatnya hal ini mengganggu kinerja petugas Sub Unit Rekam Medik, dan menghambat pelayanan pasien yang akan berobat kembali, karena harus menunggu petugas mencari keberadaan berkas Rekam Medis pasien tersebut. Hal ini tentu akan menimbulkan pertanyaan bagaimana dengan Sumber Daya Manusia yang merupakan tenaga pelaksana Rekam Medis melakukan pengisian maupun pemeriksaan kelengkapan berkas Rekam Medis di ruangan rawat inap, bagaimana dengan berkas Rekam Medis yang diisi dan diperiksa kelengkapannya tersebut, dan apakah dalam melakukan pengisian maupun pemeriksaan tersebut, Sumber Daya Manusia yang ada sudah mematuhi prosedur yang berlaku di Rumah Sakit Haji Jakarta.
Pada dasarnya pengembalian berkas Rekam Medis yang tepat waktu dari ruangan rawat inap terkait dengan pengisian berkas tersebut di ruangan rawat inap, untuk itu penulis melakukan penelitian dengan salah satu tujuan khusus mengetahui bagaimana Sumber Daya Manusia melakukan pengisian berkas Rekam Medis di ruangan rawat inap.
Jenis penelitian ini merupakan penelitian cross sectional dengan rnenggunakan metoda kualitatif. Data-data dan informasi yang diperoleh peneliti selama penelitian adalah melalui wawancara mendalam, observasi, dan data-data sekunder.
Hasil penelitian menunjukkan bahwa proses pengisian berkas Rekam Medis rawat inap di Rumah Sakit Haji Jakarta yang dilakukan oleh tenaga pelaksana belum dilaksanakan dengan baik, karena masih ada beberapa tenaga medik, maupun tenaga paramedis yang belum sempurna dalam melakukan pengisian karena kendala-kendala yang ada.
Untuk mengatasi hat tersebut, prosedur pengelolaan Rekam Medis yang sudah bagus terutama untuk rawat inap memang perlu setiap kali disosialisasikan khususnya kepada tenaga pelaksana Rekam Medis di Rumah Sakit Haji Jakarta.
Daftar Bacaan: 18 (198.5-1999)
<hr>
In-patient Medical Record Management In Jakarta Pilgrim's HospitalThe aim of medical record management in hospital is in order to support achieved administration order in the framework of effort reached for the hospital purposes, that is improvement of health care quality in the hospital, therefore to manage medical record, every hospital has to always refers to guidelines of medical record management was made by that hospital.
The guidelines of medical record management in a certain hospital basically regulated the process of activities which was begun, when the patient was admitted to admission, recording the medical data during the patient had medical care, until handling the records of patient that comprises retention and removal records from the storage to serve requisition if the patient will be treated again or other necessity.
In medical record management, recording medical data to the patient records during the patient had medical care, until sending back the records from the in-patient, out-patient, and emergency care unit forms the one of the important thing which had been regulated in the guidelines of medical record management in Jakarta Pilgrim's Hospital.
To in-patient, sending back the medical record which had been recorded completely and correctly to the Department of Medical Record is 2x24 hours after the patient out of the hospital, whereas to out patient and emergency care, sending back the records after health care or shift of the duty. In particular of sending back the in-patient records, it was necessary more concerned, because the problem which will be faced by the hospital will be more and more complex in its consequences, both medico legal aspects and claim of the third party are had to he enclosed by discharge summary.
Based on pre-research interview with the head of Medical Record Department, the staff of Medical Record Department, the head of in-patient unit, and several nurses, and observation which had done in several in-patient rooms of Jakarta Pilgrim's Hospital during November 2000, there were many medical records enough which was not sent back on time, finally its disturbed performance of Medical Record Department staff and obstructed the patient health care which will be treated again, because they have to wait for the staff was looking for medical record of the patient. Certainly it will caused the question about how did the human resources who are forms medical record caretaker do recording and examining medical record completeness at in-patient room, how did the medical record which had been recorded and had been examined its completeness, and what did they do recording and examining, the human resources have obeyed the procedure that had been done in Jakarta Pilgrim's Hospital.
Basically, sending back the medical records on time from the in-patient room was connected by recording that records at in-patient room, there for the writers do the research with the one of special purposes to know how the human resources did recording the medical record at in-patient room.
Kind of this research forms cross sectional research by the qualitative method. Data and information which were acquired researcher during the research by in-depth interview, observation, and secondary data means.
The result of the research showed that recording the in-patient medical record process in Jakarta Pilgrim's Hospital who had been done by the caretaker were not to do well, because there were still several medics, and paramedics who were not complete yet to do recording because of many obstacles.
To overcome that, the medical record management procedure which had been good especially for in-patient, really need every time was socialized particularly to the medical record caretaker in Jakarta Pilgrim's Hospital.
Bibliography: 18 (1985-1999)</description><identifier>http://lontar.ui.ac.id/detail?id=72622</identifier><recordID>72622</recordID></dc>
|
| format |
Thesis:Masters Thesis Thesis:Bachelors |
| author |
Saraswanto Setyawan, author Add author: Budi Utomo, supervisor Add author: Ronnie Rivany, examiner Add author: Amila Megraini, examiner Add author: Ahmad Husni, examiner Add author: Widyawati, examiner |
| title |
Pengelolaan rekam medis rawat inap di rumah sakit Haji Jakarta = In-patient medical record management in Jakarta Pilgrim's Hospital |
| publisher |
Fakultas Kesehatan Masyarakat Universitas Indonesia |
| publishDate |
2001 |
| topic |
Medical records |
| url |
http://lontar.ui.ac.id/detail?id=72622 |
| contents |
Tujuan pengelolaan Rekam Medis di rumah sakit adalah untuk menunjang tercapainya tertib administrasi dalam rangka upaya mencapai tujuan rumah sakit, yaitu peningkatan mutu pelayanan kesehatan di rumah sakit, oleh sebab itu dalam mengelola Rekam Medis, setiap rumah sakit harus selalu mengacu kepada pedoman/petunjuk teknis pengelolaan Rekam Medis yang dibuat oleh rumah sakit yang bersangkutan.
Pedoman/petunjuk teknis pengelolaan Rekam Medis pada suatu rumah sakit pada dasamya mengatur proses kegiatan yang dimulai pada saat diterimanya pasien di tempat penerimaan pasien, pencatatan data medis pasien selama pasien tersebut mendapatkan pelayanan medis, sampai pada penanganan berkas Rekam Medis pasien yang meliputi kegiatan penyimpanan serta pengeluaran berkas dari tempat penyimpanan untuk melayani perrnintaan/peminjaman bila pasien berobat ulang atau keperluan lain.
Dalam hal pengelolaan Rekam Medis, pencatatan data medis dalam berkas Rekam Medis pasien selama pasien tersebut mendapatkan pelayanan medis sampai pada pengembalian berkas Rekam Medik tersebut dari ruangan rawat inap, rawat jalan, maupun rawat darurat merupakan salah satu hal penting yang telah diatur di dalam pedoman pengelolaan Rekam Medik di Rumah Sakit Haji Jakarta.
Untuk rawat inap, pengembalian berkas Rekam Medis yang telah diisi dengan lengkap dan benar ke Sub Unit Rekam Medis adalah 2x24 jam setelah pasien keluar rumah sakit, sedangkan untuk rawat jalan dan rawat darurat, pengembalian berkas Rekam Medis setelah usai pelayanan atau shift tugas. Khusus untuk pengembalian berkas Rekam Medis rawat inap, hal ini perlu lebih diperhatikan, karena masalah yang akan dihadapi oleh rumah sakit akan lebih banyak dan lebih kompleks akibatnya, balk itu dari segi Mediko-Legal maupun tagihan dari pihak ketiga yang harus disertai resume medis.
Berdasarkan wawancara pra penelitian dengan Kepala Sub Unit Rekam Medis, seorang staf pada Sub Unit Rekam Medik, Kepala Unit Rawat inap dan beberapa perawat, serta pengamatan yang dilakukan di beberapa ruangan rawat imp Rumah Sakit Haji Jakarta selama bulan November tahun 2000, terdapat cukup banyak berkas Rekam Medik yang dikembalikan terlambat, akibatnya hal ini mengganggu kinerja petugas Sub Unit Rekam Medik, dan menghambat pelayanan pasien yang akan berobat kembali, karena harus menunggu petugas mencari keberadaan berkas Rekam Medis pasien tersebut. Hal ini tentu akan menimbulkan pertanyaan bagaimana dengan Sumber Daya Manusia yang merupakan tenaga pelaksana Rekam Medis melakukan pengisian maupun pemeriksaan kelengkapan berkas Rekam Medis di ruangan rawat inap, bagaimana dengan berkas Rekam Medis yang diisi dan diperiksa kelengkapannya tersebut, dan apakah dalam melakukan pengisian maupun pemeriksaan tersebut, Sumber Daya Manusia yang ada sudah mematuhi prosedur yang berlaku di Rumah Sakit Haji Jakarta.
Pada dasarnya pengembalian berkas Rekam Medis yang tepat waktu dari ruangan rawat inap terkait dengan pengisian berkas tersebut di ruangan rawat inap, untuk itu penulis melakukan penelitian dengan salah satu tujuan khusus mengetahui bagaimana Sumber Daya Manusia melakukan pengisian berkas Rekam Medis di ruangan rawat inap.
Jenis penelitian ini merupakan penelitian cross sectional dengan rnenggunakan metoda kualitatif. Data-data dan informasi yang diperoleh peneliti selama penelitian adalah melalui wawancara mendalam, observasi, dan data-data sekunder.
Hasil penelitian menunjukkan bahwa proses pengisian berkas Rekam Medis rawat inap di Rumah Sakit Haji Jakarta yang dilakukan oleh tenaga pelaksana belum dilaksanakan dengan baik, karena masih ada beberapa tenaga medik, maupun tenaga paramedis yang belum sempurna dalam melakukan pengisian karena kendala-kendala yang ada.
Untuk mengatasi hat tersebut, prosedur pengelolaan Rekam Medis yang sudah bagus terutama untuk rawat inap memang perlu setiap kali disosialisasikan khususnya kepada tenaga pelaksana Rekam Medis di Rumah Sakit Haji Jakarta.
Daftar Bacaan: 18 (198.5-1999)
<hr>
In-patient Medical Record Management In Jakarta Pilgrim's HospitalThe aim of medical record management in hospital is in order to support achieved administration order in the framework of effort reached for the hospital purposes, that is improvement of health care quality in the hospital, therefore to manage medical record, every hospital has to always refers to guidelines of medical record management was made by that hospital.
The guidelines of medical record management in a certain hospital basically regulated the process of activities which was begun, when the patient was admitted to admission, recording the medical data during the patient had medical care, until handling the records of patient that comprises retention and removal records from the storage to serve requisition if the patient will be treated again or other necessity.
In medical record management, recording medical data to the patient records during the patient had medical care, until sending back the records from the in-patient, out-patient, and emergency care unit forms the one of the important thing which had been regulated in the guidelines of medical record management in Jakarta Pilgrim's Hospital.
To in-patient, sending back the medical record which had been recorded completely and correctly to the Department of Medical Record is 2x24 hours after the patient out of the hospital, whereas to out patient and emergency care, sending back the records after health care or shift of the duty. In particular of sending back the in-patient records, it was necessary more concerned, because the problem which will be faced by the hospital will be more and more complex in its consequences, both medico legal aspects and claim of the third party are had to he enclosed by discharge summary.
Based on pre-research interview with the head of Medical Record Department, the staff of Medical Record Department, the head of in-patient unit, and several nurses, and observation which had done in several in-patient rooms of Jakarta Pilgrim's Hospital during November 2000, there were many medical records enough which was not sent back on time, finally its disturbed performance of Medical Record Department staff and obstructed the patient health care which will be treated again, because they have to wait for the staff was looking for medical record of the patient. Certainly it will caused the question about how did the human resources who are forms medical record caretaker do recording and examining medical record completeness at in-patient room, how did the medical record which had been recorded and had been examined its completeness, and what did they do recording and examining, the human resources have obeyed the procedure that had been done in Jakarta Pilgrim's Hospital.
Basically, sending back the medical records on time from the in-patient room was connected by recording that records at in-patient room, there for the writers do the research with the one of special purposes to know how the human resources did recording the medical record at in-patient room.
Kind of this research forms cross sectional research by the qualitative method. Data and information which were acquired researcher during the research by in-depth interview, observation, and secondary data means.
The result of the research showed that recording the in-patient medical record process in Jakarta Pilgrim's Hospital who had been done by the caretaker were not to do well, because there were still several medics, and paramedics who were not complete yet to do recording because of many obstacles.
To overcome that, the medical record management procedure which had been good especially for in-patient, really need every time was socialized particularly to the medical record caretaker in Jakarta Pilgrim's Hospital.
Bibliography: 18 (1985-1999) |
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