ABSTRAK

Rekam medis merupakan bagian penting membantu pelaksanaan

pemberian pelayanan kepada pasien di rumah sakit. Hal ini berkaitan dengn isi
rekam medis mencerminkan segala informasi pasien sebagai dasar menentukan
tindakan upaya pelayanan maupun tindakan medis lain. Menurut Permenkes No.
269 Tahun 2008 rekam medis adalah berkas berisikan catatan dan dokumen
tentang identitas pasien, pemeriksaan, pengobatan, tindakan dan pelayanan lain
yang telah diberikan kepada pasien. Kegunaan utamanya dilihat dari aspek
administrasi, medis, hukum, keuangan, penelitian, pendidikan dan dokumentasi.
Namun, dalam pelaksanaanya masih ditemukan rekam medis tidak dicatat
lengkap. Sanksi diberikan terhadap dokter jika tidak mengisi lengkap rekam
medis diatur dalam Undang-undang RI No. 29 Tahun 2004 tentang Praktik
Kedokteran.
Penelitian bertujuan menganalisis kelengkapan berkas rekam medis di
RSU Haji Medan Tahun 2016. Jenis penelitian deskriptif dengan pendekatan
kualitatif. Menggunakan metode wawancara dengan pendalaman pertanyaan
kepada sembilan informan yang terdiri dari emapat Dokter Spesialis Dasar, dua
Perawat, Managemen Rumah Sakit, Kepala Petugas Rekam Medis, dan Petugas
Pendaftaran Tempat Pasien Rawat Inap.
Hasil penelitian tingkat kelengkapan rekam medis rata-rata 60%, tidak
lengkap 40%. Tanggal masuk lengkap sebanyak 97%, Waktu masuk lengkap
sebanyak 95%, Anamnase lengkap sebanyak 48%, Pemeriksaan Fisik lengkap
sebanyak 47%, Diagnosa lengkap sebanyak 31%, pengobatan/tindakan lengkap
sebanyak 71%, Persetujuan Tindakan lengkap sebanyak 100%, Catatan Observasi
Klinis lengkap sebanyak 71%, Ringkasan Pulang lengkap sebanyak 31% dan
Nama dan Tanda Tangan Dokter lengkap sebanyak 79%. Ketidak lengkapan
pengisian rekam medis disebabkan waktu dokter terbatas, pengetahuan kurang
tentang pemanfaatan rekam medis terkait ALFRED, kurang kerjasama antara
dokter dan perawat, kurangnya sosialisasi, tidak ada evaluasi dan pengawasan dari
panitia rekam medis dan juga tidak ada sanksi yang diberikan.
Disarankan panitia rekam medik harus berani dan tegas mengingatkan
dokter untuk melengkapi rekam medis, memberikan sanksi yang tegas, diperlukan
SOP dan disosialisasikan merata, memberikan pelatihan, dan melakukan
pengawasan dan evaluasi secara rutin

Kata Kunci : Kelengkapan, pengisian Rekam Medis

Universitas Sumatera Utara

 ABSTRACT

Medical records is an important part of helping the implementation of the

provision of service to patients in the hospital. This relates to the contents of the
medical records reflect all patient information as a basis for determining the
actions of medical care efforts and other measures. According to the minister
regulation. 269 of 2008 medical records are files containing records and
documents about the identity of the patient, examination, treatment, action, and
other servicesthat have been provided to the patient. Its main use from the aspects
of administration, medical, legal, finance, research, education and
documentation. However, in practice still found a complete medical records.
Sanctions imposed againts the doctor if it does not fill the complete medical
records set in RI Law No. 29 of 2004 on the practice of medicine.
The research aims to analyze the completeness of medical record in the
hospital file Haji Medan at Year 2016 Type a descriptive study with qualitative
approach. Using interviews with deepening questions to nine informants
consisting of four Specialist Doctors Association, two Nurse, Hospital
Management, Chief Medical Record Officers and Registration Officers Inpatient
place.
The results of the research level of completeness of medical records an
average of 60%, not 40% complete. In Date complete as much as 97%, in time
complete as much as 95%, Anamnase complete as much as 48%, Physical
Examination complete as much as 47%, Diagnosis complete as much as 31%,
treatment/ completed act as much as 71%, the Agreement Complete action as
much as 100%, notes Observations Detailed clinical as much as 71%, full Round
summary as much as 31% and name and Signature Physician complete as much
as 79%. The lack of charging accessories medical records due to limited
physician time, lack of knowledge about the use of medical records related
ALFRED , lack of cooperation between doctors and nurses , lack of socialization ,
no evaluation and supervision of medical records committee and also no
punishment will be given.
The committee suggested the medical record must be bold and resolute
remind doctors to complete medical records, providing strict sanctions, necessary
SOP and disseminated evenly, provide training, and monitoring and evaluation on
a regular basis.

Keywords: completeness, filling medical record

Universitas Sumatera Utara