Tinjauan Kelengkapan Penulisan Nama Pasien Dalam Rekam Medis Di Rumah Sakit (Literature Review)
DOI:
https://doi.org/10.55606/klinik.v3i1.2193Kata Kunci:
Completeness of Writing Patient NamesAbstrak
Background: According to the Regulation of the Minister of Health of the Republic of Indonesia Number 24 of 2022 concerning Medical Records, they are documents that contain patient identity data, examinations, treatment, procedures and other services that have been provided to patients. Hospital Minimum Service Standards Completeness of medical record filling 24 hours after completion must reach 100%. Objective: To determine the completeness factor in writing the patient's name in the patient's medical record at the hospital. Method: This research used the literature review method which was carried out on 14 journals and found incompleteness in writing patient names in hospital medical records. Results: Of the 14 journals regarding the completeness of writing patient names, none of the research results found were close to the very good category (100%). The highest percentage of completeness in writing patient names was found in research journals with a percentage of 98%, while the lowest percentage was 56%. Conclusion: From the results of a review of the completeness of writing patient names in hospital medical records, 14 journals were found to not have 100% completeness results and not all hospitals have SOPs regarding procedures for writing patient names. Suggestion: Create an SPO for procedures for writing patient names that comply with standards so that officers can carry out these activities with guidelines.
Referensi
Ahmad Maliki, Saimi,Heru Purnama. (2018). Analisis Ketidaklengkapan Dokumen Rekam Medis Pada Kasus Rawat Inap Di Rsud Patut Patuh Patju Gerung. Jurnal Kesehatan Qamarul Huda, 6(1), 17–23. https://doi.org/10.37824/jkqh.v6i1.2018.8
Arimbi, A. D., Muflihatin, I., & Muna, N. (2021). Analisis kuantitatif kelengkapan pengisian formulir informed consent rumkital dr. Ramelan surabaya j-remi : jurnal rekam medik dan informasi kesehatan. 2(2), 221–229.
Erminia, E., & Pratama, R. Y. (2018). Tinjauan kelengkapan Pengisian Lembar Ringkasan Pulang Unit Rawat Inap. Jurnal Perekam Medis Dan Informasi Kesehatan, 1(2), 46–51. http://journal.stikes-kapuasraya.ac.id/index.php/JUPERMIK/article/view/102
Fadilah, N., Dewi, D. R., Fannya, P., & Muniroh, M. (2022). Tinjauan Kelengkapan Rekam Medis Rawat Inap Pada Kasus Demam Berdarah Dengue Di Rumah Sakit Angkatan Laut Marinir Cilandak. Jurnal Kesehatan Tambusai, 3(3), 500–508. https://doi.org/10.31004/jkt.v3i3.7008
Gebbrien Anggia, D. (2021). Tinjauan Penulisan Nama Pasien pada Map Rekam Medis di Rumah Sakit Mekar Sari Bekasi. 5(2), 43–49.
Giyatno, & Rizkika, M. Y. (2020). Analisis Kuantitatif Kelengkapan Dokumen Rekam Medis Pasien Rawat Inap Dengan Diagnosa Fracture Femur Di Rsud Dr. R.M. Djoelham Binjai. Jurnal Ilmiah Perekam Dan Informasi Kesehatan Imelda (JIPIKI), 5(1), 62–71. https://doi.org/10.52943/jipiki.v5i1.349
Gustiara, B., Dewi, D. R., & Fannya, P. (2022). Analisis kelengkapan rekam medis rawat inap di rumah sakit bhakti mulia tahun 2022. 3, 559–569.
Indah Susilowati, Ratna Frenty Nurkhalim, L. H. T. 2022. (2022). Tinjauan Prosedur Kelengkapan Pencatatan Data Demografi Pasien Baru Di Rsud X Trenggalek Review Of Recording Completeness New Demography Data At Rsud X Trenggalek. 62–70.
Kemenkes RI. (2007). Peraturan Menteri Kesehatan Republik Indonesia Nomor 512 Tahun 2007 tentang Izin Praktik Dan Pelaksanaan Praktik Kedokteran. In Peraturan Menteri Kesehatan Republik Indonesia Nomor 512/Menkes/Per/IV/2007 (p. 4).
Kepmenkes No 129 Tahun 2008. (2008). Kepmenkes No 129 Tahun 2008 Standar Pelayanan Minimal Rs. Kepmenkes No 129 Tahun 2008 Standar Pelayanan Minimal Rs, 49(1), 69–73. https://www.slideshare.net/f1smed/kepmenkes-no129tahun2008standarpelayananminimalrs
Khonsa, S., Widjaja, L., Fannya, P., Jumiati, S., & Safitri, Y. (2022). Indonesian Journal of Health Information Management ( IJHIM ) Vol . 2 No . 2 ( 2022 ), 1 Analisis Kuantitatif Kelengkapan Formulir Pengkajian Medis Awal Dokter Pada Rekam Medis Pasien Rawat Inap Di RS Vertikal Jakarta Timur Overview of Initial Doctor Init. 2(2), 1–9.
Lily Widjaja. (2014). Sistem rekam medis dan manajeman informasi kesehatan. In lily widjaja (ke 1, Vol. 1). universitas esa unggul.
Made Maha Karma Wirajaya, N. M. U. K. D. (2019). Analisis Ketidaklengkapan Rekam Medis Pasien Rawat Inap di Rumah Sakit Dharma Kerti Tabanan. Jurnal Administrasi Rumah Sakit Indonesia, 6(1), 11–20. https://doi.org/10.7454/arsi.v6i1.3553
Mekhtildis Suryati. (2021). Gambaran Kelengkapan Pengisian Resume Medis di Rumah Sakit Umum Daerah Ende. Jurnal Manajemen Informasi Dan Administrasi Kesehatan (JMIAK), 5(1), 77–86.
Nurrachma Yulianti. (2022). Sosains jurnal sosial dan sains. Jurnal Sosial Dan Sains, 2(2), 278–285.
Permenkes Nomer 24. (2022). Peraturan Menteri Kesehatan Republik Indonesia Nomor 24 Tahun 2022. Kemenkes, 8.5.2017, 2003–2005.
Sansy Dua Lestari, Daniel Happy Putra, Deasy Rosmala Dewi, & Laela Indawati. (2022). Tinjauan Kelengkapan Resume Medis Pasien Rawat Inap di Rumah Sakit Islam Jakarta Sukapura. SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat, 1(2), 165–174. https://doi.org/10.55123/sehatmas.v1i2.130
Suaryanti, N. M. A., Maha Wirajaya, M. K., & Sudiari, M. (2022). Analisis Kelengkapan Rekam Medis Pasien Rawat Inap Fraktur Tulang Anggota Gerak di Rumah Sakit Bhayangkara Denpasar. Jurnal Kesehatan Vokasional, 7(2), 70. https://doi.org/10.22146/jkesvo.67626
Undang-undang RI No. 44. (2009). Undang-undang RI No. 44 tahun2009. Tentang Rumah Sakit, 10, 2–4.
