Abstract
The discharge summary is a resume of all patient care and treatment periods that must be filled in entirely by the doctor in charge within 1x24 hours after the patient is pronounced discharged. This study examines the completeness and timeliness of filling in discharge summaries by using the system approach. This research is a qualitative study to obtain input and transformation through in-depth interviews and review of hospital documents, then reinforced with quantitative research to get an overview of the output through observation and study of discharge summary forms. Sixty one discharge summary forms were used as research samples by calculating total sampling. The results showed that the percentage of discharge summaries included in the category fulfilled was only 16.4%. At the same time, in terms of timeliness, it was found that only 45.9% of filling discharge summaries were included in the appropriate time accuracy category. The average time needed for a doctor to get a discharge summary is 32.3 hours. The patient identity and the nursing data items group had the lowest filling distribution, while the highest was in the medical data and data authentication group. There are still differences in knowledge in filling out discharge summary, lack of motivation of the doctors, form formats evaluation that has not been carried out routinely; there is no reward system, punishment system and special training for discharge summary, differences in perceptions regarding the flow of the discharge summary filling process, and the discovery of conflicts related to communication.
Bahasa Abstract
Resume medis merupakan ringkasan dari seluruh masa perawatan dan pengobatan pasien yang wajib diisi lengkap oleh Dokter Penanggung Jawab Pasien (DPJP) dalam 1x24 jam setelah pasien pulang. Penelitian ini dilakukan untuk menganalisis kelengkapan dan ketepatan waktu pengisian resume medis menggunakan pendekatan sistem. Jenis penelitian kualitatif digunakan untuk mendapatkan gambaran input dan transformasi melalui wawancara mendalam serta telaah dokumen, yang kemudian diperkuat dengan penelitian kuantitatif untuk mendapatkan gambaran output, melalui observasi dan telaah formulir. Terdapat 61 sampel formulir resume medis dengan menggunakan perhitungan total sampling. Hasil penelitian menunjukkan bahwa persentase resume medis yang termasuk ke dalam kategori terpenuhi lengkap hanya 16,4%, sedangkan dari segi ketepatan waktu ditemukan hanya 45,9% pengisian resume medis yang termasuk ke dalam kategori tepat waktu. Rata-rata waktu pengisian resume medis yaitu 32,3 jam. Kelompok item identitas pasien dan data perawatan memiliki distribusi keterisian terendah, sedangkan distribusi keterisian tertinggi terdapat pada kelompok item data medis dan data autentikasi. Masih terdapat perbedaan pengetahuan dalam pengisian resume medis, kurangnya motivasi dokter, evaluasi format formulir yang belum rutin dilaksanakan, adanya inkonsistensi kebijakan rumah sakit, belum ada sistem reward dan punishment untuk dokter, belum ada diklat khusus resume medis, terdapat perbedaan persepsi mengenai alur pengisian resume medis, serta konflik dalam komunikasi interpersonal.
Recommended Citation
Savitri, Febriana and Putri, Septiara
(2023)
"KELENGKAPAN DAN KETEPATAN WAKTU PENGISIAN RESUME MEDIS ≤1X24 JAM OLEH DOKTER DI RSIA SMB TAHUN 2020,"
Jurnal ARSI (Administrasi Rumah Sakit Indonesia): Vol. 9:
No.
3, Article 4.
DOI: 10.7454/arsi.v9i3.7623
Available at:
https://scholarhub.ui.ac.id/arsi/vol9/iss3/4