ANALISA REVIEW KUANTITATIF DAN KUALITATIF DOKUMEN REKAM MEDIS KASUS BEDAH ORTHOPEDI PADA PERIODE TRIWULAN IV DI RUMAH SAKIT MARDI RAHAYU KUDUS TAHUN 2015 - UDiNus Repository

DAFTAR ISI
Halaman
Halaman Judul ..................................................................................

i

Halaman Hak Cipta ...........................................................................

ii

Halaman Persetujuan ........................................................................

iii

Halaman Pengesahan .......................................................................

iv

Halaman Pernyataan Keaslian Karya Tulis Ilmiah .............................

v

Halaman Pernyataan Persetujuan Publikasi Karya Ilmiah Untuk
Kepentingan Akademis ......................................................................

vi

Halaman Persembahan .....................................................................

vii

Halaman Riwayat Hidup ....................................................................

viii

Kata Pengantar .................................................................................

ix

Abstrak ..............................................................................................

xi

Daftar Isi ............................................................................................

xiii

Daftar Tabel.......................................................................................

xvi

Daftar Gambar ...................................................................................

xviii

Daftar Lampiran .................................................................................

xix

Daftar Singkatan ................................................................................

xx

BAB I PENDAHULUAN
A. LatarBelakang .............................................................................

1

B. RumusanMasalah ........................................................................

3

C. TujuanPenelitian ..........................................................................

4

D. Manfaat Penelitian .......................................................................

5

E. Ruang Lingkup ............................................................................

5

F. Keaslian Penelitian ......................................................................

6

BAB II TINJAUAN PUSTAKA
A. RekamMedis ................................................................................

10

B. Formulir Rekam Medis Rawat Inap…………………………………

12

C. Fungsi Dan Tugas Assembling……………………………………. ..

12

D. Quality Assurance…………………………………………………… .

13

E. Ketentuan Pengisian Dokumen Rekam Medis……………………..

17

F. Pengaruh Dari Ketidaklengkapan Isi Dokumen Rekam Medis….... 18
G. Bedah Orthopedi………………………………………………………

19

H. Kerangka Teori ……………………………………………………… .

21

BAB III METODE PENELITIAN
A. Kerangka Konsep ........................................................................

22

B.

JenisPenelitian ...........................................................................

22

C.

Variabel Penelitian .....................................................................

23

D.

Definisi Operasional ...................................................................

24

E.

Populasi Dan Sampel .................................................................

26

F.

Pengumpulan Data.....................................................................

27

G. Pengolahan Data .......................................................................

27

H.

28

AnalisisData ..............................................................................

BAB IV HASIL PENELITIAN
A. Gambaran Umum Rumah Sakit Mardi Rahayu Kudus ................

29

B. Gambaran Umum RMIK Rumah Sakit Mardi Rahayu Kudus .......

34

C. Hasil Pengamatan .......................................................................

48

BAB V PEMBAHASAN
A. Review Identifikasi .......................................................................

59

B. Review Pencatatan ......................................................................

60

C. Review Autentikasi ......................................................................

61

D. Review Pelaporan........................................................................

61

E. Review Kelengkapan dan kekonsistensian Diagnosa ..................

62

F. Review Kekonsistensian Pencatatan Diagnosa ...........................

63

G. Review Pencatatan Hal-Hal Yang Dilakukan Saat Perawatan
Dan Pengobatan ..........................................................................

64

H. Review Pencatatan Informed Consent .........................................

65

I.

65

Review Cara Pencatatan .............................................................

J. Review Hal-Hal Yang Berpotensi Menyebabkan Tuntutan Ganti
Rugi .............................................................................................

66

K. DMR ............................................................................................

66

BAB VI PENUTUP
A. KESIMPULAN .............................................................................

68

B. SARAN ........................................................................................

70

DAFTAR PUSTAKA ..........................................................................

72

LAMPIRAN ........................................................................................

74