EVALUASI IMPLEMENTASI REKAM MEDIS TERINTEGRASI DI INSTALASI RAWAT INAP RSUP DR. SARDJITO YOGYAKARTA

Abstract

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. T he
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.
Keywords: evaluation, integrated notes, medical records