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Rumah sakit sebagai penyedia jasa pelayanan kesehatan harus terus meningkatkan mutu pelayanan kesehatannya salah satunya dilihat dari mutu rekam medis. Mutu rekam medis yang baik dilihat dari kelengkapan pengisian berkas rekam medis. Tujuan penelitian ini adalah untuk mengetahui gambaran kelengkapan pengisian berkas rekam medis rawat inap di RSIA X tahun 2016. Penelitian ini bersifat deskriptif observasional dan merupakan penelitian kualitatif. Total seluruh berkas adalah 325 berkas rekam medis pasien rawat inap. Berdasarkan pedoman wawancara hasil penelitian untuk sumber daya manusia di RSIA X memenuhi standar yang ditetapkan mencakup latar belakang pendidikan, masa kerja pegawai yang berhubungan dengan kelengkapan pengisian, pengetahuan dan pelatihan secara khusus terkait pengisian rekam medis yang dilakukan secara berkala. Kebijakan atau prosedur pengisian rekam medis yang diterapkan di RSIA X sudah lengkap, hanya user harus diberikan sosialisasi kembali tentang pengisian berkas rekam medis yang lengkap. Sarana dan prasarana sudah cukup memadai dan sesuai standar. Berdasarkan lembar observasi total kelengkapan rekam medis rawat inap RSIA X bulan Desember 2016 sebesar 76,8%, untuk formulir rujukan mencapai 100% dan formulir lainnya belum mencapai total 100%, total kelengkapan berdasarkan Permenkes No. 269 Tahun 2008 tentang Rekam Medis sebesar 57,8%. Artinya, kelengkapan pengisian berkas rekam medis sudah cukup lengkap namun masih kurang dari standar kelengkapan Depkes RI tahun 2008. Untuk itu, perlu dilakukan penelitian proses pengisian rekam medis RSIA X untuk mengetahui proses pengisian rekam medis sudah sesuai dengan yang ditetapkan oleh RSIA X.
ABSTRACT
Hospitals, as health care providers, should always promote the quality of their health care services. One way to measure the quality of health care service by a hospital is by evaluating the quality of their medical records. The aim of this study is to understand the completeness or corehensive filling of medical records of inpatients at RSIA X in 2016. This is a descriptive observational study and is a qualitative researc The amount of files studied were 325 files of inpatients. The results of human resources at RSIA X already meet the established standard one of which consists of educational background, employee's working period related to completeness of filling, knowledge related to medical record, special training related to medical record which can be done periodically. The policy or procedure of filling medical record that is applied in RSIA X is complete, only user that fill still have to be given socialization again in order to complete the medical record file, facilities and infrastructure is a supporting factor in the completeness of filling in medical records of inpatients. This study was that the completeness of medical record filling of inpatients at RSIA X in December 2016 was 76.8%, referral forms reached 100%, while other forms did not reach 100%. The completeness of medical record filling based on Permenkes No.269 2008 on Medical Records was 57.8%. This shows that the medical record filling was relatively sufficient, however, it was still below the standards of medical record filling established by Depkes RI 2008. For that, it is necessary to research the process of filling medical record RSIA X to know the process of filling the medical record is in accordance with that set by RSIA X.