Gambaran Kelengkapan dan Kesesuaian Pengisian Rekam Medis Gigi di Puskesmas Tanawangko Kabupaten Minahasa Tahun 2018 – 2022
DOI:
https://doi.org/10.35790/eg.v12i1.50801Abstract
Abstract: Concerning victim identity, dental medical record can be used as the victim’s data before death (antemortem) compared with data after death (postmortem). Incompleteness of the medical record describes the health services provided and the quality of the medical record. Incomplete medical record documents can interfere with health workers in identifying a patient's medical history. This study aimed to describe the completeness and suitability of dental medical records at Tanawangko primary health center (PHC) in 2018–2022 in terms of dental medical record guidelines compiled by the Directorate of Basic Health Efforts, Ministry of Health, Republic of Indonesia in 2015. This was a descriptive and observational study using simple random sampling method. The population included all dental medical record data at Tanawangko PHC in 2018 – 2022. The results showed that the average completeness and suitability of all dental medical records at Tanawangko PHC was relatively low and there were no odontogram sheets and patient supporting sheets found. In conclusion, the completeness and suitability of dental medical records at Tanawangko PHC is relatively low.
Keywords: completeness and suitability of data; dental medical record; victim identification
Abstrak: Saat diperlukan penentuan identitas individu, pengumpulan bukti pengisian rekam medis gigi dapat dijadikan sebagai data korban sebelum meninggal (antemortem) yang dibandingkan dengan data korban setelah meninggal (postmortem). Ketidaklengkapan pengisian rekam medis menggambar-kan pelayanan kesehatan yang diberikan dan mutu pelayanan rekam medis. Dokumen rekam medis yang tidak lengkap dapat menyulitkan petugas kesehatan untuk mengidentifikasi riwayat medis pasien. Penelitian ini bertujuan untuk mengetahui gambaran kelengkapan dan kesesuaian rekam medis gigi di Puskesmas Tanawangko tahun 2018–2022 ditinjau dari panduan rekam medis gigi yang disusun oleh Direktorat Bina Upaya Kesehatan Dasar Kementrian Kesehatan RI tahun 2015. Jenis penelitian ialah deskriptif observasional menggunakan metode simple random sampling dengan populasi seluruh data rekam medis gigi di Puskesmas Tanawangko pada tahun 2018–2022. Hasil penelitian memperlihatkan bahwa rerata kelengkapan dan kesesuaian seluruh rekam medis gigi di Puskesmas Tanawangko masih tergolong rendah, serta tidak ditemukannya lembar odontogram dan lembar lampiran penunjang pasien. Simpulan penelitian ini ialah kelengkapan dan kesesuaian seluruh rekam medis gigi di Puskesmas Tanawangko masih tergolong rendah.
Kata kunci: kelengkapan dan kesesuaian data; rekam medis gigi; identifikasi korban
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