Pendampingan Petugas Rekam Medik Dalam Pembuatan Formulir Gawat Darurat Berdasarkan Standar Akreditasi Rumah Sakit Versi 2012 Di RSD BalungJember
Abstract
Based on pre survey in Balung General Hospital, showed that emergency form has not qualified with hospital acreditation standard (version 2012) for early medic and nursing assessment. The aim of this research is to re-design emergency forms based on hospital acreditation standard (version 2012) in Balung General Hospital 2016. This research is qualitative study. The data collection method are observation, interview and brainstorming. The result of this research is viewed from physical aspect of early medic and nursing assessment using white paper in size of A4 80 gram (21 x 29.7cm) in potrait lay out. Based on anatomy aspect, the heading of early medic and nursing assessment form is to put logo, the name and the full address of the instance, the introduction which should be appropriate with the aim of the form that are early medic and nursing assessment. Based on the content aspect of the early medic assessment form, the additional data consits of a kind of triage, the date of arrival and handling, the ealy survey of ABCD, painful scale, medicine allergic, fungtional status, falldown risk. Based on the nursing assessment form, it consists of patient's identity, primary survey, secondary survey, nursing diagnose, act plan, selfnurse-act, collaboration act, nursing evaluation, further action, given tasks and nirse autentication. Hopefully, the researcher's suggestion related to the result of early medic and nursing assessment form design can be applied in Balung General Hospital, Jember
References
Cahyono, Hendra Dwi. 2016. Buku Ajar Keperawatan Gawat Darurat. Jember : Akademi Keperawatan Dokter Soebandi.
Depkes RI, 2006. Pedoman Penyelenggaraan dan Prosedur Rekam Medis Rumah Sakit di Indonesia (Revisi II). Jakarta: Direktorat Jenderal Bina Upaya Pelayanan Medik.
-------------. 2014. Peraturan Menteri Kesehatan Republik Indonesia Nomor 56 Tahun 2014 tentang Klasifikasi dan Perijinan Rumah Sakit. Jakarta : Departemen Kesehatan RI.
Hatta, G. R. 2014. Pedoman Manajemen Informasi Kesehatan Disarana Pelayanan Kesehatan. (G. R. Hatta, Ed.) Revisi III. Jakarta: Penerbit Universitas Indonesia (UI-Press).
Haq, A. A. 2015. Evaluasi dan Desain Formulir Ringkasan Masuk Dan Keluar Di Klinik Rawat Inap Dr. M Suherman Universitas Muhammadiyah Jember. Politeknik Negeri Jember.
Huffman, Edna K. 1999. Health Information Management. Translate Ekardius. (R. Jennifer Cofer, Ed.).
Kemendagri RI. 2009. Undang-Undang Republik Indonesia Nomor 44 Tahun 2009 tentang Rumah Sakit. Jakarta: Departemen Kesehatan RI.
Menkes RI. 2009. Keputusan Menteri Kesehatan Republik Indonesia Nomor 856 Tahun 2009 tentang Instalasi Gawat Darurat.
Pengantar, K. 2012. Instrumen Akreditasi Rumah Sakit Standar Akreditasi Versi 2012.
Peraturan Menteri Kesehatan RI Nomor 012 Tahun 2012 tentang Akreditasi Rumah Sakit.
Whardani, D. R. 2015. Evaluasi dan Perancangan Formulir Pendaftaran Rawat Jalan Pasien Baru di RSU Haji Surabaya. Jember. Politeknik Negeri Jember.
