KEAKURATAN REKAM MEDIS BERDASARKAN LAPORAN INSIDEN PASIEN JATUH DI RUMAH SAKIT

Authors

  • Savitri Citra Budi
  • Annisa Nurdini
  • Sunartini Sunartini
  • Lutfan Lazuardi
  • Fatwa Sari Tetra

Keywords:

Incidence of Patients, Patient Injuries Due to Falling, Patient Safety, Medical Record Accuracy

Abstract

PENDAHULUAN: Rekam medis berisi semua bukti pelayanan yang diberikan tenaga kesehatan, termasuk dokumentasi pelayanan setelah terjadinya insiden pada pasien. Pada kasus terjadinya insiden, seharusnya tenaga kesehatan mengisikan riwayat pelayanan yang telah diberikan pada rekam medis. Penelitian ini memfokuskan pada pendokumentasian tenaga kesehatan pada rekam medis berdasarkan laporan insiden yang diakibatkan karena pasien jatuh. Tujuan penelitian ini: mengetahui persentase jumlah insiden pasien jatuh, variasi insiden pasien jatuh, dan keakuratan rekam medis pasien yang mengalami insiden jatuh.

METODE: Jenis penelitian ini adalah penelitian deskriptif dengan pendekatan kuantitatif. Rancangan penelitian dengan cross-sectional. Lokasi penelitian di rumah sakit tipe B Pendidikan di Kota Wates Kabupaten Kulon Progo. Populasi penelitian adalah laporan insiden keselamatan pasien tahun 2018 dan rekam medis pasien yang mengalami insiden jatuh berdasarkan laporan insiden tahun 2018. Analisis data menggunakan analisis univariat. 

HASIL: Distribusi frekuensi insiden pasien jatuh ditemukan sebesar 16,7% (n=11) dari total insiden. Ditemukan ada 8 variasi pasien jatuh selama pelayanan di rumah sakit tahun 2018. Hasil analisis keakuratan rekam medis dilihat dari pendokumentasian tindakan tenaga kesehatan setelah terjadinya insiden ditemukan 100% tidak akurat.

KESIMPULAN: Tenaga kesehatan belum mendokumentasikan tindakan yang diberikan pada rekam medis setelah terjadinya insiden pada pasien. Monitoring terkait keakuratan rekam medis sebagai bukti pelayanan perlu ditingkatkan. 

 

Kata kunci: Insiden Pasien, Cedera Pasien Akibat Terjatuh, Keselamatan Pasien, Keakuratan Rekam Medis

 

 

INTRODUCTION: Medical records contain all evidence of services provided by health workers, including documentation of services after the incident occurred in patients. In the case of an incident, health workers should fill in the service history that has been provided in the medical record. This study focuses on documenting health workers in medical records based on incident reports caused by patients falling. The purpose of this study: to determine the percentage of the number of incidents of patients falling, variations in the incidence of patients falling, and the accuracy of the medical records of patients who experienced a fall incident.

METHOD: This type of research is a descriptive study with a quantitative approach. Research design with cross-sectional. The location of the study in Type B Education hospitals in the City of Wates in Kulon Progo Regency. The study population was a report on incidents of patient safety in 2018 and medical records of patients who experienced a fall incident based on an incident report in 2018. Data analysis used univariate analysis.

RESULTS: The frequency distribution of falling patient incidents was found to be 16.7% ??(n = 11) of the total incidents. It was found that 8 variations of patients fell during the service in the hospital in 2018. The results of the analysis of the accuracy of the medical records seen from the documentation of the actions of health workers after the incident were found to be 100% inaccurate.

CONCLUSION: Health workers have not documented the actions given to the medical record after the incident occurred in the patient. Monitoring related to the accuracy of medical records as proof of service needs to be improved.

 

Keywords: Incidence of Patients, Patient Injuries Due to Falling, Patient Safety, Medical Record Accuracy

 

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Published

2019-03-24