Upaya Perbaikan Ketidaklengkapan Pengisian Berkas Rekam Medis Rawat Inap Pasien Bpjs Kesehatan Dengan Pendekatan Plan, Do, Check, Action (Pdca) Di Rsud Dr. r. Soedarsono Pasuruan Tahun 2019

Solehah, Dianatus (2020) Upaya Perbaikan Ketidaklengkapan Pengisian Berkas Rekam Medis Rawat Inap Pasien Bpjs Kesehatan Dengan Pendekatan Plan, Do, Check, Action (Pdca) Di Rsud Dr. r. Soedarsono Pasuruan Tahun 2019. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Ketidaklengkapan pengisian rekam medis memengaruhi mutu pelayanan rekam medis dengan jumlah persentase tertinggi terkait ketidaklengkapan pengisian berkas rekam medis rawat inap pada pasien BPJS Kesehatan yaitu sebesar 56% dan jumlah terendah sebesar 51% di RSUD dr. R. Soedarsono Kota Pasuruan. Tujuan dari penelitian adalah menyusun upaya ketidaklengkapan pengisian berkas rekam medis rawat inap pada pasien BPJS Kesehatan tahun 2019 dengan pendekatan Plan, Do, Check, Action. Penelitian ini dilakukan di RSUD dr.R. Soedarsono Pasuruan di bulan November 2019 - Januari 2020. Penelitian ini dilakukan secara kualitatif dengan pendekatan PDCA. Teknik Pengumpulan data yang digunakan adalah wawancara, observasi, kuesioner, dokumentasi dan brainstorming dengan enam subjek penelitian yaitu 1 dokter, 1 perawat, 1 apoteker, 1 ahli gizi, dan 2 perekam medis. Prioritas penyebab masalah ketidaklengkapan pengisian berkas rekam medis rawat inap pada pasien BPJS kesehatan yaitu belum pernah dilakukan pelatihan ketidaklengkapan pengisian rekam medis dan tidak adanya SOP pengisian berkas rekam medis rawat inap. Hasil penelitian ini dijelaskan dari tahapan Plan membuat SPO (Standar Prosedur Operasional). Tahapan Do, SPO yang telah dibuat kemudian didiskusikan, dan diimplementasikan selama 1 bulan pada bulan Januari 2020. Tahapan Check didapat hasil sebelum implementasi SPO kelengkapan pengisian berkas rekam medis didapat persentase ketidaklengkapan yaitu 48% sedangkan hasil setelah implementasi SOP persentase ketidaklengkapan menjadi 39,49%. Tahapan Action, menetapkan SOP kelengkapan pengisian berkas rekam medis rawat inap. Saran melakukan monitoring, evaluasi kinerja petugas dalam pengisian rekam medis dengan menyesuaikan SOP kelengkapan pengisian berkas rekam medis rawat inap pada pasien BPJS Kesehatan. Kata Kunci: BPJS, PDCA, Standar Prosedur Operasional, Rekam Medis. Improvement efforts the incompleteness form filling of the medical record from patients hospitalization at BPJS Health using approach methods Plan, Do, Check, Action (PDCA) at the Hospital Dr. R. Soedarsono Pasuruan Year 2019 Advisor Atma Deharja, S.KM., M.Kes Dianatus Solehah Program Study of Medical Record Department of Health Program Studi D-IV Rekam Medik Jurusan Kesehatan ABSTRACT The incompleteness of filling medical records had inevitably affected the quality of medical record service occurred in a regional public hospital (RSUD) dr. R Soedarsono in Pasuruan City, East Java. The highest percentage of this case had been by 56%, while the lowest was about 51%. This research purposes to compile the incompleteness of filling inpatient medical records for patients of the 2019 Healthcare and Social Security Agency (BPJS) by using the approach of Plan, Perform, Check, and Act (PDCA), conducted from November 2019 to January 2020 at RSUD dr. R. Soedarsono. It used in qualitative by employing the PDCA, the of data collection by using the method of interview, observation, questionnaire, documentation and brainstorming with six research subjects consisting of doctor, nurse, pharmacist, nutritionist, and medical recorders. Yet, the cause of the matter led to a delay in the claim process of BPJS. The results of this research are started at the step of the plan by making SPO (Standard Operating Procedures), followed by the step of do by which the SPO was discussed and then implemented a month in January 2020. In the next step, the check was by filling the inpatient medical record documents for the BPJS patients had not fully met it obtained that the results before the implementation of the SPO for completing medical record filling, the percentage of incompleteness was 48%, while the results after the implementation of the SOP showed that the percentage of incompleteness was 39.49%. The last step was action concluded by forming a team to handle the incompleteness of filling inpatient medical record documents for BPJS’s patients. This was oriented to facilitate monitoring related to the completeness of filling the inpatient medical record documentation and the SPO that would still be implemented by RSUD dr. R. Soedarsono. For a logical suggestion, hospitals used to establish SOPs that have been prepared as well as to monitor and evaluate the performance of staffs regarding the completeness of filling the special inpatient medical record documentation for the patients of BPJS. Keywords: BPJS, PDCA, Standard Operating Procedures, Medical Record.

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