Evaluasi Implementasi Rekam Medis Terintegrasi di Instalasi Rawat Inap RSUP DR. Sardjito Yogyakarta
Penulis/Author
Patricia Suti Lasmani (1); Dr. Fitri Haryanti, S.Kp., M.Kes. (2); dr. M. Lutfan Lazuardi, M.Kes., Ph.D. (3)
Tanggal/Date
2014
Kata Kunci/Keyword
Abstrak/Abstract
Background: There was an interview with medical forensic sub-committee at Dr. Sardjito Hospital that stated no medical record was complete. Separated patient-monitoring reflected poor colaboration among medical staffs. Hence, Dr. Sardjito
Hospital had implemented integrated medical records for inpatients and there should be an evaluation f or the implementation. Objective: This study aimed to evaluate documentation process of integrated medcal records for inpatients at Dr. Sardjito
Hospital through completeness, patient-centered care, interprofesional
collaboration and confidentiality aspects. Second, it aimed to explore barriers and enablers of implementation of integrated medical records. Methods: T his study is a case study with descriptiveexplanatory design. Main data source was documentation on medical records of three to six days inpatients. The documentation proess was aimed for obtaining quantitative data of medical records-completeness. Triangulation of observation and focus group discussion was done f or obtaining qualitative data. Results: Implementation of integrated medical records was poor. None of medical records had standard abbreviation. Medical records which had no signed correction were 29.7% and only 41.6% of medical records had date and time written, while those with non-clear and simplified notes were 61.5%. However, most medical records had complete progress note (85.4%) and equipped with clear name and signed by the
caregivers (81.3%). Focus group discussion resulted that integrated medical records was giving benefit. Integrated medical records provided better service to patients.
Conclusion: Dr. Sardjito Hospital has to obliged its medical staffs to implement integrated medical records for better services to patients.
