Gambaran Pelaksanaan Rekam Medis di Balai Pengobatan Rumah Sakit Gigi dan Mulut Universitas Sam Ratulangi Manado berdasarkan Permenkes RI Nomor 269 Tahun 2008
DOI:
https://doi.org/10.35790/eg.1.2.2013.3127Abstract
Rekam medis merupakan berkas yang berisi catatan dan dokumen identitas pasien, hasil pemeriksaan, pengobatan yang telah diberikan serta tindakan dan pelayanan lain yang telah diberikan kepada pasien. Rekam medis sangat penting dalam pelayanan bagi pasien karena selain dapat memberikan informasi untuk menentukan keputusan dalam pengobatan, penanganan serta tindakan medis tetapi juga mempunyai peranan yang sangat penting dalam menjadi alat bukti untuk menyelesaikan perkara hukum. Kewajiban dokter dan dokter gigi dalam membuat rekam medis dalam tempat praktik, puskesmas dan rumah sakit telah diatur dalam Peraturan Menteri Kesehatan Republik Indonesia Nomor 269 tahun 2008 yang di dalamnya tentang pengisian rekam medis dengan akurat, lengkap dan tepat waktu. Jenis penelitian ini adalah penelitian deskriptif yang bertujuan untuk mengetahui pelaksanaan rekam medis di BP-RSGM Unsrat Manado berdasarkan Permenkes RI no 269 tahun 2008 tentang rekam medis. Populasi dalam penelitian ini adalah data rekam medis yang ada di BP-RSGM Unsrat Manado pada tahun 2010-2012 dan besar sampel dalam penelitian ini diambil dengan menggunakan rumus deskriptif kategorik. Analisa data diolah secara manual dalam bentuk persentase, dianalisis kemudian disajikan dalam bentuk tabel distribusi frekuensi dan grafik disertai penjelasan. Kesimpulannya, kelengkapan pengisian rekam medis di BP-RSGM Unsrat Manado mencapai 96,3% dan pelaksanaan rekam medis belum seluruhnya (100 %) sesuai, penyimpanan rekam medis yang merupakan sampel penelitian 100 % sudah sesuai, kerahasiaan rekam medis hanya 20 % yang sesuai, pengorganisasian, pembinaan dan pengawasan rekam medis 100% tidak sesuai dengan permenkes Nomor 269 Tahun 2008. Diharapkan untuk dokter / tenaga kesehatan yang mengisi rekam medis di BP-RSGM Unsrat Manado hendaknya mengisi seluruh catatan rekam medis dengan lengkap dan dikelola dengan baik sesuai dengan permenkes Nomor 269 Tahun 2008 serta adanya pembinaan dan pengawasan pelaksanaan peraturan rekam medis oleh pimpinan BP-RSGM Unsrat Manado maupun kepala dinas kesehatan dan organisasi profesi terkait.
Kata kunci: rekam medis, pelaksanaan, permenkes RI nomor 269 Tahun 2008
ABSTRACT
Medical records are files containing patient records and identity documents, test results, treatment given and actions and other services that have been provided to the patient. Medical records are very important in the service for the patient because in addition to providing information to determine treatment decisions, treatment and medical treatment but also has a very important role in being evidence to settle lawsuits. Obligations of doctors and dentists in making medical records in place practices, health centers and hospitals have been set in the Minister of Health of the Republic of Indonesia No. 269 of 2008 in which about charging medical records with accurate, complete and timely. This research is a descriptive study that aimed to determine the implementation of the medical records in the BP - RSGM Unsrat Manado based Minister of Health of the Republic of Indonesia No. 269 of 2008 concerning medical records . The population in this study were medical records that exist in the
BP-RSGM Unsrat Manado in 2010-2012 and the sample size in this study were taken by using a formula categorical descriptive. Analysis of the data processed manually in the form of a percentage, analyzed and then presented in the form of frequency distribution tables and charts with explanation. In conclusion, the complete filling medical record at BP-RSGM Unsrat Manado reached 96.3% and the implementation of the medical record has not been entirely (100%) corresponding, record-keeping, a sample of 100% is appropriate, the confidentiality of medical records is only 20% were appropriate, organizing, coaching and supervision medical records are not 100% in accordance with Health Minister Regulation No. 269 of 2008. Expected to doctors / health workers who fill medical records in BP-RSGM Unsrat Manado should fill the entire medical record with complete and properly managed in accordance with the Minister of Health No. 269 of 2008 as well as the guidance and supervision of the implementation of the regulations by the leadership of the medical records of BP-RSGM Unsrat Manado and the head head of health and related professional organizations.
Keywords: medical records, execution, Minister of Health the Republic of Indonesia No. 269 of 2008
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