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MEDICAL AUDIT SUMMARY

I.

Topic

II.

Number of Medical
Record

i. Pilih layanan kritikal yang


berdampak pada mutu layanan
ii. layanan tersebut sangat mugkin
untuk ditingkatkan mutunya
i. RM dari seluruh kasus ( jika
jumlah kasusnya sedikit)
ii. Sampel dari RM yang dipilh
secara random sampling (jika
jumlah kasusnya banyak)

III.

Indicator

Variable yang dapat digunakan


untuk mengukur perubahan mutu

IV.

Criterion

Tujuan (mis: seluruh pasien pasca


hernia repair mestinya tidak boleh
terjadi infeksi pasca operasi)

V.

Standard

Tingkat pemenuhan terhadap


kriteria yang telah ditetapkan dan
dapat diterima.
Mis: hasil audit dianggap baik jika
mencapai atau melampaui 95 %
dari kriteria

VI.

Result

Bandingkan kinerja dengan


standar atau kriteria yang telah
ditetapkan

VII. Analysis

identify problems and causes


for change

VIII. Revise

how to on the difference

IX.

observe practice after change

Re-audit

(Sumber bacaan: Yadav, H.: Hospital management, 2006)

Kita boleh mulai dengan menggunakan STANDAR PELAYANAN MINIMAL dari


Kemenkes atau boleh menggunakan standar lain.

Contoh Medical Audit

MEDICAL AUDIT SUMMARY


I.

Topic

II.

Number of Medical
Record

III.
IV.

Indicator
Criterion

V.
VI.

Standard
Result

insiden infeksi luka pasca


operasi hernia
vii. i. Jika jumlah kasus sedikit,
viii.
semua kasus diikut-sertakan
ii. Jika jumlah kasus banyak,
diambil sample yang dipilih
secara random (20-30 RM)
post-operative infection
tidak ada infeksi pasca operasi
(angka infeksi pasca operasi nol
persen)
95%
mutu operasi dikatakan baik atau
memuaskan jika 95% dari sampel tidak terjadi infeksi pasca
operasi, atau jika angka infeksi
hanya 5% dari sampel

VII. Analysis

identifikasi problem & penyebab


pada struktur, proses, dan hasil
(outcome) guna perubahan
rancang upaya peningkatan
mutu dengan menutup gap pada
struktur, proses, atau outcome
dilakukan audit kembali hanya
apabila rancangan peningkatan
telah dilaksanakan (misalnya
setelah enam bulan)

VIII. Revise
IX.

Re-audit

Audit Report Form


Title
Background

Aim(s) of the audit


Standards

Methodology

Results

Conclusions

Recommendations &
Action Plan

This should be the same as the title on the proforma. It


should also include the auditors name and title, the date of
the report, and the name of the individual hospital.
Clarify why the audit was done. For example, was the
project prompted by an identified local problem or
concern? The background should explain the rationale
for doing the audit. Summarise the evidence base for
the audit topic, giving full references at the end. If a
team was convened to undertake this audit, describe
how this was organised and who was involved.
Explain the aims of the project. Use BSMART guidelines
(benefits, specific, measurable, aligned/agreed, realistic, time
bound).
Outline standards, guidelines or benchmarks, and their
source and strength of evidence. If not measured against
existing standards then stated intention to set standards at
the end of the project should be included and if so, which
aspects of care those standards pertain to.
State chosen population to be audited and how the sample
was selected, specifying whether a retrospective or
prospective approach was used Identify the size of the
sample, the time period, and how this was calculated or
agreed upon. The method of data collection, a list of who was
responsible for data collection, when this was done, and the
method of data input and analysis should be included
The number and percentage of cases meeting each criteria of
the standard should be included in the data analysis. Use
graphs and charts to enhance and simplify presentation. Both
raw figures & percentages are required. Confidentiality
guidelines should be strictly followed, omitting any identifiable
information of staff and/or patients.
Present key points that flow from results - use bullet points
and avoid long paragraphs. Conclusions need to be
supported by the data, regardless whether the data points to
no firm conclusions or not. The conclusion should be
objective with factual statements
State recommendations for change should be made.
Recommendations must be realistic and achievable. An
action plan should be agreed stating what changes will be
implemented, who will be responsible for carrying them out
and when this will be done. If appropriate a date for a reaudit, if not already included in the report, should be stated
for the completion of the audit cycle.