ABSTRAK
Devina Putri Cayandra, 2019. “Pembuatan Formulir Asuhan Gizi Dikaitkan Dengan Analisis Kuantitatif Dokumen Rekam Medis Rawat Inap Di RSIA Puri” Laporan Tugas Akhir. Program Studi DIII Perekam Medis dan Informasi Kesehatan Politeknik Kesehatan Kemenkes Malang.
Pembimbing: Diniyah Kholidah, SST, S.Gz, MPH
Sistem dokumentasi rekam medis di RSIA Puri terdapat beberapa jenis formulir, salah satunya yaitu formulir Asuhan Gizi. Formulir asuhan gizi dibuat untuk menuliskan hasil dari pemeriksaan gizi pasien yang membutuhkan asuhan gizi. Rancangan penelitian yang digunakan survei deskriptif pendekatan kuantitatif. Desain penelitian yang digunakan cross sectional. Tujuan penelitian ini untuk melakukan analisa (kuantitatif) formulir asuhan gizi dan hasil penelitiannya berupa produk rancangan form yang baru (Revisi). Populasi dalam penelitian ini sebanyak 43 dokumen dari bulan Agustus-Desember 2018 dan sampelnya menggunakan total sampling 43 dokumen dari bulan Agustus-Desember 2018. Hasil penelitian ini menunjukkan bahwa keakuratan identifikasi pasien sebesar 90,60%, keakuratan pada laporan/catatan penting sebesar 0%, keakuratan autentifikasi sebesar 69,70%, keakuratan pencatatan yang baik sebesar 0%.
Kesimpulannya saat dilakukannya analisis kuantitatif, peneliti menemukan ketidaklengkapan formulir asuhan gizi di RSIA PURI mencapai 100%. Mengembangkan Desain Formulir Asuhan Gizi dengan menambahkan instruction, body bagian antropometri ditambahi poin penting yang harus diisi oleh ahli gizi, dan bagian close ditambah tanggal penyelesaian pengisian formulir.
Kata kunci: Formulir Asuhan Gizi, Analisis Kuantitatif, Desain Formulir
ABSTRACK
Abstract: Medical record documentation system in RSIA Puri has several types of forms, one of which is Nutrition Care form. Nutrition care forms are made to write down the results of nutritional examinations of patients who need nutrition care. The research design used descriptive quantitative approach survey. The research design used cross sectional. The purpose of this study was to analyze (quantitatively) the nutritional care form and the results of the research in the form of a new form design product (Revised). The population in this study were 43 documents from August- December 2018 and the sample used a total sampling of 43 documents from August-December 2018. The results of this study indicate that the accuracy of patient identification is 90.60%, accuracy in reports / important notes is 0% , the accuracy of authentication is 69.70%, the accuracy of good recording is 0%. In conclusion, when the quantitative analysis was conducted, the researchers found that the incompleteness of the nutrition care form at the RSIA PURI reached 100%. Developing a Nutrition Care Form Design by adding “instruction”, the” body” of the anthropometry is added with important points that must be filled by the nutritionist, and the part
“close” plus the completion date of the form filling.
Keywords: Nutrition Care Form, Quantitative Analysis, Form Design.
