Gambaran Implementasi Review Rekam Medis Terbuka dan Review Rekam Medis Tertutup Sesuai SNARS di Rumah Sakit Husada

Abstract

An open medical record review is an analysis performed while the patient is still in treatment. Meanwhile, a closed medical record review is an analysis that is carried out after the medical record returns to the medical record room. For the results of the open and closed medical record review reports at Husada Hospital in 2019, the results of the review are still many incomplete in filling out medical records. This study aims to determine the policies of the medical record review team, medical record review guidelines, SPO (Standard Operating Procedures), and medical record review form formats. The method used is descriptive method, which describes the results of observations with the method of observation, interviews and document review.
The results of the review of open medical records at Husada Hospital in November 2019 from 65 medical records that were reviewed were the highest element of incompleteness, namely drug reconciliation, there were 58 incomplete with a percentage of 89% and 7 (11%). As for the open medical record review in July 2019, out of 646 medical records that were reviewed, the highest element of incompleteness was an important note with a number of 505 incomplete with a percentage of 78% there were scribbles, this violates the rules in writing medical records, where the rules for writing medical records if it occurs Written errors, officers are only allowed to cross out once and give a signature. The implementation of reviewing medical records itself at Husada Hospital has not been carried out properly. The medical record review team must be more active and cooperate with each other in conducting medical record review. The most important thing is that it is necessary to socialize the doctors and health workers who care that they are responsible for completing the filling of medical records and the correctness of the contents of the medical records.
Keywords: Medical Record Review Team Policy, Medical Record Review Guide, SPO Medical Record Review

Review rekam medis terbuka merupakan suatu pelaksanaan analisis yang dilakukan saat pasien masih dalam perawatan. Sedangkan review rekam medis terutup merupakan suatu pelaksanaan analisis yang dilakukan sesudah rekam medis kembali keruang rekam medis. Untuk hasil laporan review rekam medis terbuka dan tertutup di Rumah Sakit Husada di tahun 2019 hasil review masih banyak ketidaklengkapan dalam pengisian rekam medis. Penelitian ini bertujuan untuk mengetahui kebijakan tim review rekam medis, Panduan review rekam medis, SPO (Standar Prosedur Operasional), dan format formulir review rekam medis. Metode yang digunakan adalah metode deskriptif yaitu memaparkan hasil pengamatan dengan metode observasi,wawancara, dan telaah dokumen.
Adapun Hasil dari review rekam medis terbuka di Rumah Sakit Husada pada Bulan November 2019 dari 65 rekam medis yang di review elemen tertinggi ketidaklengkapannya yaitu rekonsiliasi obat terdapat 58 yang tidak lengkap dengan persentase 89% dan yang lengkap 7 (11%). Sedangkan untuk review rekam medis terbuka pada Bulan Juli 2019 dari 646 rekam medis yang direview elemen tertinggi ketidaklengkapannya adalah catatan penting dengan jumlah 505 yang tidak lengkap dengan persentase 78 % terdapat coretan hal ini menyalahi aturan dalam penulisan rekam medis, dimana aturan penulisan rekam medis bila terjadi kesalahan penulisan petugas hanya diperkenankan untuk mencoret 1 kali dan dibubuhi tanda tangan. Untuk pelaksanaan review rekam medis sendiri dirumah sakit husada belum terlaksana dengan baik. Tim review rekam medis harus lebih aktif dan saling bekerja sama dalam pelaksanaan review rekam medis. Hal yang paling utama adalah perlu dilakukan sosoalisasi kepada dokter dan tenaga kesehatan yang merawat bahwa mereka bertanggung jawab atas kelengkapan pengisian rekam medis dan kebenaran isi rekam medis.
Kata Kunci: Kebijakan Tim Review Rekam Medis, Panduan Review Rekam Medis, SPO Review Rekam Medis