ANALISA KETIDAKLENGKAPAN DOKUMEN REKAM MEDIS RAWAT INAP PADA KASUS DEMAM THYPOID DI RUMAH SAKIT UMUM DAERAH BENDAN KOTA PEKALONGAN PERIODE TRIWULAN 1 TAHUN 2016 - UDiNus Repository

DAFTAR ISI

HALAMAN JUDUL ...................................................................................... i
HALAMAN HAK CIPTA............................................................................... ii
HALAMAN PERSETUJUAN ....................................................................... iii
HALAMAN PENGESAHAN ......................................................................... iv
HALAMAN KEASLIAN PENELITIAN .......................................................... v
HALAMAN PERNYATAAN PERSETUJUAN PUBLIKASI KTI ..................... vi
HALAMAN PERSEMBAHAN ...................................................................... vii
DAFTAR RIWAYAT HIDUP ........................................................................ viii
PRAKATA ................................................................................................... ix
ABSTRAK ................................................................................................... xi
ABSTRACT ................................................................................................ xii
DAFTAR ISI ................................................................................................ xiii
DAFTAR TABEL ......................................................................................... xvii
DAFTAR GAMBAR ..................................................................................... xviii
DAFTAR LAMPIRAN .................................................................................. xix
DAFTAR SINGKATAN ................................................................................ xx
BAB I PENDAHULUAN
A. Latar Belakang ................................................................................ 1
B. Rumusan Masalah .......................................................................... 4

C. Tujuan Penelitian ............................................................................ 4
D. Manfaat Penelitian .......................................................................... 5
E. Ruang Lingkup ................................................................................ 6
F. Keaslian Penelitian .......................................................................... 7

BAB II TINJAUAN PUSTAKA
A. Rekam Medis .................................................................................. 9
B. Formulir Rekam Medis Rawat Inap ................................................. 13
C. Demam Thypoid .............................................................................. 14
D. Quality Assurance ........................................................................... 14
E. Analisa Kuantitatif ........................................................................... 15
F. Analisa Kualitatif.............................................................................. 18
G. Kelengkapan Pengisian Dokumen Rekam Medis ........................... 20
H. Assembling ..................................................................................... 21
I.

Unit Rawat Inap............................................................................... 21

J. Kerangka Teori................................................................................ 23
BAB III METODE PENELITIAN

A. Kerangka Konsep............................................................................ 24
B. Jenis Penelitian ............................................................................... 25
C. Variabel Penelitian .......................................................................... 25
D. Definisi Operasional ........................................................................ 26
E. Populasi & Sampel .......................................................................... 29
F. Pengumpulan Data ........................................................................ 31
G. Pengolahan Data ........................................................................... 32
H. Analisis Data .................................................................................. 32
BAB IV HASIL PENGAMATAN
A. Gambaran Umum Rumah Sakit ...................................................... 33
B. Gambaran Khusus Institusi ............................................................. 38
C. Hasil Pengamatan ........................................................................... 39
a. Review Identifikasi ..................................................................... 39

b. Review Pelaporan ..................................................................... 40
c. Review Pencatatan ................................................................... 41
d. Review Autentifikasi .................................................................. 41
e. Total analisa kuantitatif masing-masing formulir ........................ 42
f.

Hasil Analisa kuantitatif masing-masing review ......................... 43

g. Kelengkapan dan kekonsistensian diagnosa ............................. 43
h. Kekonsistensian pencatatan doagnosa ..................................... 44
i.

Kekonsistensian pencatatan saat perawatan dan pengobatan .. 45

j.

Kekonsistensian cara atau praktek pencatatan diagnosa .......... 45

k. Hasil analisa kualitatif masing-masing review ............................ 46
l.

Total Hasil Kuantitatif dan Kualitatif ........................................... 47

m. Delinguent Medical Record........................................................ 47
BAB V PEMBAHASAN
1. Analisa Kuantitatif ........................................................................... 48

a. Review Identifikasi ..................................................................... 48
b. Review Pelaporan ..................................................................... 49
c. Review Pencatatan ................................................................... 50
d. Review Autentifikasi .................................................................. 50
2. Analisa Kualitatif.............................................................................. 52
a. Kelengkapan dan kekonsistensian diagnosa ............................. 52
b. Kekonsistensian pencatatan doagnosa ..................................... 53
c. Hal-hal yang dilakukan saat perawatan dan pengobatan ........... 54
d. Kekonsistensian cara atau praktek pencatatan diagnosa .......... 54
e. Delinguent Medical Record........................................................ 56

BAB VI KESIMPULAN DAN SARAN
A. Kesimpulan ..................................................................................... 57
B. Saran .............................................................................................. 59
DAFTAR PUSTAKA
LAMPIRAN