Analisis Kelengkapan Rekam Medis Berdasarkan SNARS di RSU Purwogondo Kebumen
DOI:
https://doi.org/10.25047/j-remi.v4i1.3612Keywords:
Completeness, Accreditation, SNARS, ManagementAbstract
One of the hospital's quality is determined by a complete medical record document. The completeness of medical records at the Purwogondo General Hospital in Kebumen only reached 86% of the 100% standard determined by the minimum service. Completeness of medical records is needed in order to create continuity of treatment for patients and strong legal force. This study aims to analyze the completeness of medical records based on SNARS elements. The research subjects were 6 people, namely doctors, nurses, quality team representatives, medical recorders, internal supervisors, MIRM working group officers. Data collection methods are observation, interviews and brainstorming. The results of the research on the element of man are officer discipline and communication. The money element is the absence of a budget for the monitoring and evaluation team. The method element is the absence of an SOP for reviewing the completeness of medical records. The material element is the form design that the PPA has not yet understood. The machine element is the absence of an incomplete medical record control book, no monitoring and evaluation team for the completeness of medical records. Efforts to optimize the completeness of medical records are monitoring medical records on a regular basis and optimizing the monitoring and evaluation team.
References
Permenkes RI, Peraturan Menteri Kesehatan Republik Indonesia Nomor 269/MENKES/PER/III/2008 tentang Rekam Medis. 2008, p. 7.
Kepmenkes RI, Keputusan Menteri Kesehatan RI Nomor 129 Tahun 2008 Tentang Standar Pelayanan Minimal Rumah Sakit. Jakarta, 2008.
F. D. Ayuningtyas, “Kelengkapan Ringkasan Pasien Pulang Rawat Inap Berdasarkan Elemen Penilaian MIRM 15 SNARS1 di RS Mata ‘dr. YAP’ Yogyakarta,” 2018.
F. S. Mardeni, F. Hakam, and Y. Asriat, “Analisis Review Kelengkapan Formulir Ringkasan Pulang dalam Pemenuhan Elemen Penilaian MIRM 15 SNARS Edisi 1 di Rumah Sakit Muhammadiyah Selogiri,” J. Manaj. Inf. dan Adm. Kesehat. ISSN, vol. 03, no. November, pp. 12–20, 2020.
S. Notoatmodjo, Metodologi Penelitian Kesehatan. Jakarta: Rineka Cipta, 2018.
A. Febria, “Analisis Kelengkapan Pengisian Berkeas Rekam Medis Rawat Inap Berdasarkan Elemen Penilaian MIRM 13.3 Standar Nasional Akreditasi Rumah Sakit di RSUD Kabupaten Temanggung,” UNiversitas Gadjah Mada, 2018.
G. R. Hatta, Pedoman Manajemen Informasi Kesehatan di Sarana Pelayanan Kesehatan. Jakarta: UI Press, 2018.
M. A. Rahmawati, N. Nuraini, and D. A. Hasan, “Analisis Faktor Penyebab Keterlambatan Penyediaan Dokumen Rekam Medis Rawat Jalan di RSU Haji Surabaya,” J-REMI J. Rekam Med. Dan Inf. Kesehat., vol. 1, no. 4, pp. 511–518, 2020.
A. A. Paulus, Y. Dharmawan, and F. Agushybana, “Faktor-Faktor yang Berhubungan dengan Kelengkapan Dokumen Rekam Medis Rawat Inap di Rumah Sakit tahun 2018,” J. Kesehat. Masy., vol. 7, pp. 395–403, 2019.
I. Indar, “Faktor-Faktor yang Berhubungan dengan Kelengkapan Rekam Medis di RSUD H. Padjonga Dg. Ngalle Takalar,” Universitas Hasanudin, 2013.
T. G. Wati and N. Nuraini, “J-REMI : Jurnal Rekam Medik Dan Informasi Kesehatan Analisis Kejadian Missfile Berkas Rekam Medis Rawat Jalan di Puskesmas Bangsalsari J-REMI : Jurnal Rekam Medik Dan Informasi Kesehatan,” vol. 1, no. 1, pp. 23–30, 2019.
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