Analising RM Oktober SD Desember 2019
Analising RM Oktober SD Desember 2019
BU
IDENTIFIKASI
PASIEN KELENGKAPAN LAPORAN / FORM YANG PE
Site marking
kmr opeasi
Tgl lahir
NO No RM
No RM
Nama
CPPT
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
1 253155 1 1 1 1 1 0 1 1 1 0 1 1 1 1
2 253145 1 1 1 1 1 1 1 1 1 1 1 1 1 1
3 252881 1 1 1 1 1 1 1 1 1 1 1 1 1 1
4 253028 1 1 1 1 1 1 1 1 1 1 1 1 1 1
5 253025 1 1 1 1 1 1 1 1 1 1 1 1 1 1
6 252540 1 1 1 1 1 1 1 1 1 1 1 1 1 1
7 246618 1 1 1 1 1 1 1 1 1 1 1 1 1 1
8 252868 1 1 1 1 1 1 1 1 1 1 1 1 1 1
9 252850 1 1 1 1 1 1 1 1 1 1 1 1 1 1
10 235010 1 1 1 1 1 1 1 1 0 1 1 1 1 1
11 251552 1 1 1 1 1 1 1 1 1 1 1 1 1 1
12 191122 1 1 1 1 1 1 1 1 1 1 1 1 1 1
13 252859 1 1 1 1 1 1 1 1 1 1 1 1 1 1
14 252747 1 1 1 1 1 1 1 1 1 1 1 1 1 1
15 253164 1 1 1 1 1 1 1 1 1 1 1 1 1 1
16 252679 1 1 1 1 1 1 1 1 1 1 1 1 1 1
17 253028 1 1 1 1 1 1 1 1 1 1 1 1 1 1
18 252881 1 1 1 1 1 1 1 1 1 1 1 1 1 1
19 218445 1 1 1 1 1 1 1 1 1 1 1 1 1 1
20 249546 1 1 1 1 1 1 1 1 1 1 1 1 1 1
21 243658 1 1 1 1 1 1 1 1 1 1 1 1 1 1
22 253255 1 1 1 1 1 1 1 1 1 1 1 1 1 1
23 206879 1 1 1 1 1 1 1 1 0 1 1 1 1 1
24 197411 1 1 1 1 1 1 1 1 1 1 1 1 1 1
232823 1 1 1 1 1 1 1 1 1 1 1 1 1 1
25
26 251765 1 1 1 1 1 1 1 1 1 1 1 1 1 1
27 248667 1 1 1 1 1 1 1 0 1 0 0 1 1 0
28 210626 1 1 1 1 1 1 1 1 1 1 1 1 1 1
29 253168 1 1 1 1 1 1 1 1 1 1 1
30 241130 1 1 1 1 1 1 1 1 1 1 1 1 1 1
31 253468 1 1 1 1 1 0 0 0 1 0 0 1 1 0
32 253137 1 1 1 1 1 1 1 1 1 1 1 1 1 1
33 253345 1 1 1 1 1 1 1 1 1 1 1 1 1 1
34 253493 1 1 1 1 1 1 1 1 1 1 1 1 1 1
35 250703 1 1 1 1 1 1 1 1 1 1 1 1 1 1
36 253380 1 1 1 1 1 1 1 1 1 1 1 1 1 1
37 253377 1 1 1 1 1 1 1 1 0 1 1 1 1 1
38 246529 1 1 1 1 1 1 1 1 1 1 1 1 1 1
39 252931 1 1 1 1 1 1 1 1 1 1 1 1 1 1
40 253116 1 1 1 1 1 1 1 1 1 1 1 1 1 1
41 253434 1 1 1 1 1 1 0 1 1 1 0 1 1 0
42 253382 1 1 1 1 1 1 1 1 1 1 1 1 1 1
43 253158 1 1 1 1 1 1 1 1 1 1 1 1 1 1
44 252931 1 1 1 1 1 1 1 1 1 1 1 1 1 1
45 253424 1 1 1 1 1 1 1 1 1 1 1 1 1 1
46 248812 1 1 1 1 1 1 1 1 1 1 1 1 1 1
47 211050 1 1 1 1 1 1 1 1 1 1 1 1 1 1
48 139932 1 1 1 1 1 1 0 1 1 1 1 1 1 1
49 253534 1 1 1 1 1 1 0 1 1 1 0 1 1 1
50 253607 1 1 1 1 1 1 1 1 1 1 1 1 1 1
51 252884 1 1 1 1 1 1 1 1 1 1 1 1 1 1
52 253299 1 1 1 1 1 1 1 1 1 0 1 1 1 1
53 253301 1 1 1 1 1 1 1 1 1 1 1 1 1 1
54 253302 1 1 1 1 1 1 1 1 1 1 1 1 1 1
55 251716 1 1 1 1 1 1 1 1 1 1 1 1 1 1
56 252020 1 1 1 1 1 1 1 1 1 1 1 1 1 1
57 246727 1 1 1 1 1 1 1 1 1 1 1 1 1 1
58 253254 1 1 1 1 1 1 1 1 1 1 1 1 1 1
59 250868 1 1 1 1 1 1 1 0 1 1 1 1 1 1
60 253474 1 1 1 1 1 1 1 1 1 1 1 1 1 1
61 248336 1 1 1 1 1 1 1 1 1 1 1 1 1 1
62 253483 1 1 1 1 1 1 1 1 1 1 1 1 1 1
63 248667 1 1 1 1 1 1 1 1 1 1 1 1 1 1
64 183448 1 1 1 1 1 1 1 1 1 1 1 1 1 1
65 251428 1 1 1 1 1 1 1 1 1 1 1 1 1 1
66 249882 1 1 1 1 1 1 1 1 1 1 1 1 1 1
67 253152 1 1 1 1 1 1 1 1 1 1 1 1 1 1
68 253691 1 1 1 1 1 1 1 1 1 1 1 1 1 1
69 253650 1 1 1 1 1 1 1 1 0 1 1 1 1 1
70 251664 1 1 1 1 1 1 1 1 1 1 1 1 1 1
71 253258 1 1 1 1 1 1 1 1 1 1 1 1 1 1
72 210174 1 1 1 1 1 1 1 1 1 1 1 1 1 1
73 252165 1 1 1 1 1 1 1 1 1 1 1 1 1 1
74 247211 1 1 1 1 1 1 1 1 1 1 1 1 1 1
75 253679 1 1 1 1 1 1 1 1 1 1 1 1 1 1
76 253791 1 1 1 1 1 1 1 1 1 1 1 1 1 1
77 253539 1 1 1 1 1 1 1 1 1 1 1 1 1 1
78 252807 1 1 1 1 1 1 1 1 1 1 1 1 1 1
79 250261 1 1 1 1 1 1 1 1 1 1 1 1 1 1
80 253762 1 1 1 1 1 1 1 1 1 1 1 1 1 1
81 253982 1 1 1 1 1 1 1 1 1 1 1 1 1 1
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
total 81 81 81 81 81 79 77 78 77 77 77 80 80 77
Ket :
Tidak Lengkap / Tidak Ada = 0
Lengkap / Ada = 1
ANALISIS KUANTITATIF RM RAWAT RAWAT INAP
BULAN OKTOBER 2019
AUTENTIKASI CATATAN YANG
APORAN / FORM YANG PENTING PENULIS BAIK
TTd perawat
Nama Dr.
TTd Dr
17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 26
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
0 0 1 0 1 1 1 1 1 1 1 1 1 0 0 0 20
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
11
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
0 0 1 0 1 1 0 1 1 1 1 1 1 0 0 0 17
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
0 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 26
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 26
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
0 0 1 1 1 1 1 1 0 1 1 1 1 0 0 0 21
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 0 0 1 0 0 0 25
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 0 1 1 0 0 0 26
1 1 1 1 1 1 1 1 1 0 1 1 1 0 0 0 25
0 0 1 1 1 1 1 1 1 1 1 1 1 0 0 0 23
1 1 1 1 1 1 1 1 1 1 0 0 1 0 0 0 25
1 1 1 1 1 1 0 1 1 1 0 1 1 0 0 0 25
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 26
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 0 1 1 0 0 0 26
1 1 1 1 1 1 1 1 1 1 0 1 1 0 0 0 26
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 26
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 26
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 0 1 1 1 0 0 0 26
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 0 1 1 1 0 0 0 26
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 27
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
75 76 80 78 80 80 78 80 79 77 74 78 80 0 0 2122
KET
34
tidak ada nama dan ttd cppt, Lembar persetujuan Dokter, Cek List Pre Operasi tidak ada
tidak ada nama perawat ctt pre op, petugas Efek samping
obat
RM 57,33,32 (nama perawat)
Batal Operasi
Batal Operasi
Batal Operasi
RM07. RM34
RM07,
Batal Operasi
rm07, rm57
rm07
rm 07
rm 07
rm 13
rm14
ANALISIS DATA BULAN SEPTEMBER
TOTAL
TOTAL PERSEN PERSEN
NO FORM REKAM MEDIS TIDAK JUMLAH LENGKAP TIDAK
LENGKAP LENGKAP LENGKAP
PLAN DO
Mengupayakan agar kelengkapan - Menyiapkan dan mengecek
pengisian berkas rekam medis ketersediaan formulir berkas
mencapai target sebesar 100% rekam medis
- Meningkatkan pengawasan
terhadap pengisian berkas rekam
medis
ENGISIAN BERKAS REKAM MEDIS
STUDY ACTION
Berdasarkan hasil dari data yang - Mengingatkan dan
dikumpulkan tentang pengisian mensosialisasi kan lagi
berkas rekam medis yaitu : kepada unit terkait untuk
dapat teliti dan
memperlengkap semua
1. Kelengkapan pengisian pengisian berkas rekam
Persetujuan rawat inap dibulan medis
Juli hanya mencapai 68%, di
bulan Agustus 100% dibulan
September 88% dengan total
rata rata 85% pengisian - Sosialisasi tentang
pengisian berkas rekam
medis yang dilaksanakan 3
hari kedepan
96
6. Resume ringkasan pulang Juli 100
96%, Agustus 100% September
99% 99