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Tri Ariani
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Journal : Jurnal Informasi Kesehatan Indonesia (JIKI)

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ANALISIS KELENGKAPAN LEMBAR LAPORAN OPERASI PADA REKAM MEDIS PASIEN BEDAH DI RSU PKU MUHAMMADIYAH BANTUL Dwi Ratna Sari; Nurvita Wikansari; Tri Ariani
Jurnal Informasi Kesehatan Indonesia (JIKI) Vol 8 No 1 (2022): Jurnal Informasi Kesehatan Indonesia
Publisher : Politeknik Kesehatan Kemenkes Malang (State Health Polytechnic of Malang)

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Abstract

Background: Surgery is one of the services carried out by the hospital. The surgical report sheet must be completely filled out and signed by the doctor who performed the operation and must be made immediately after surgery, then entered into the patient's medical record. The incompleteness of filling out the surgical report can result in unclear sequence of procedures, this can cause serious problems, especially if it goes to court. The purpose of this study was to determine the completeness of the surgery report and the factor of incompleteness of the surgery report sheet at RSU PKU Muhammadiyah Bantul. Subjects and Method: This type of research is mixed methodology, data collection using observation checklist tables, and interview sheets. The population in this study was a surgical patient visit report sheet in April 2022 with a sample of 100 operating report sheets. The research subjects were 2 surgeons and 2 nurses. Results: The completeness of the surgical report for the identification section was 88.75%, the important report section was 95.58%, the authentication section was 100%, and the documentation section was good at 98%. The factor causing the incomplete surgical report is because of the doctors and nurses are busy, causing the operation report sheet to be incomplete. Conclusion: It is recommended that there be course to doctors and nurses regarding the importance of completeness of medical records, especially operating report sheets, and collaboration between medical record officers, nurses, and doctors who treat patients. Keywords: Completeness, Medical Records, Surgery Report, Surgical Patient.
ANALISIS KELENGKAPAN LEMBAR LAPORAN OPERASI PADA REKAM MEDIS PASIEN BEDAH DI RSU PKU MUHAMMADIYAH BANTUL Dwi Ratna Sari; Nurvita Wikansari; Tri Ariani
Jurnal Informasi Kesehatan Indonesia (JIKI) Vol 8 No 1 (2022): Jurnal Informasi Kesehatan Indonesia
Publisher : Politeknik Kesehatan Kemenkes Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31290/jiki.v8i1.3145

Abstract

Latar Belakang: Tindakan operasi adalah salah satu pelayanan yang dilaksanakan oleh rumah sakit. Lembar laporan operasi harus terisi lengkap dan ditandatangani oleh dokter yang melakukan operasi dan harus segera dibuat setelah pembedahan, kemudian dimasukkan kedalam rekam medis milik pasien. Ketidaklengkapan pengisian lembar laporan operasi dapat mengakibatkan ketidakjelasan urutan prosedur, hal ini dapat menimbulkan permalasahan serius terutama jika sampai pengadilan. Tujuan dari penelitian ini adalah untuk mengetahui kelengkapan lembar laporan operasi dan faktor ketidaklengkapan lembar laporan operasi di RSU PKU Muhammadiyah Bantul. Subjek dan Metode: Jenis penelitian ini adalah mixed methodology, pengumpulan data menggunakan tabel checklist observasi, dan lembar wawancara. Populasi dalam penelitian ini adalah lembar laporan operasi kunjungan pasien bedah di bulan April 2022 dengan sampel 100 lembar laporan operasi. Subjek penelitian 2 dokter bedah dan 2 perawat. Hasil: Hasil penelitian secara umum menunjukkan kelengkapan lembar laporan operasi bagian identifikasi sebesar 88,75%, bagian laporan penting sebesar 95,58%, bagian autentifikasi sebesar 100%, dan bagian pendokumentasian yang baik sebesar 98%. Faktor penyebab ketidaklengkapan lembar laporan operasi yaitu karena kesibukan dokter dan perawat, sehingga menyebabkan lembar laporan operasi tidak terisi dengan lengkap. Kesimpulan: Sebaiknya diadakan sosialisasi kepada dokter dan perawat mengenai pentingnya kelengkapan rekam medis khususnya lembar laporan operasi, serta diperlukan kerjasama antara petugas rekam medis, perawat, dengan dokter yang menangani pasien.
Co-Authors Agustina Agustina Dwi Ratna Sari Edi Sarwoko Nina Trisna Nurvita Wikansari Ovilia putri utami gumay Satinem Satinem