Tinjauan Kelengkapan Pengisian Lembar Persetujuan Anestesi Pasien Rawat Inap Bangsal Umum Kelas Iii Triwulan 3 Di Rumah Sakit Umum Mitra Paramedika - Repository Unjaya

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TINJAUAN KELENGKAPAN PENGISIAN LEMBAR PERSETUJUAN ANESTESI PASIEN RAWAT INAP BANGSAL UMUM KELAS III TRIWULAN 3 DI RUMAH SAKIT UMUM MITRA PARAMEDIKA

Siti Nurrull Abibah¹Suryo Nugroho Markus²

INTISARI

Latar belakang: Kualitas mutu rumah sakit dapat dilihat rekam medisnya, salah satunya pada tingkat kelengkapan pengisian lembar persetujuan anestesi. Upayanya adalah untuk meningkatkan mutu suatu rumah sakit pasien dilakukan operasi harus diketahui tanda tangan persetujuan anestesi pada berkas rekam medis anestesi rawat inap bangsal umum kelas III triwulan 3. Berdasarkan hasil studi pendahuluan bahwa tingkat kelengkapan pengisian lembar persetujuan anestesi di Rumah Sakit Umum Mitra Paramedika masih kurang dalam pengisiannya.

Tujuan: Tujuan penelitian ini adalah mengetahui kelengkapan pengisian lembar persetujuan anestesi di Rumah Sakit Umum Mitra Paramedika.

Metode: Jenis penelitian ini adalah deskriptif kuantitatif dengan rancangan Cross- Sectional. Subjek penelitian ini ada 3 sebagai berikut: 1 dokter, 1 perawat, 1 kepala instalasi rekam medis. Subjek ini adalah 56 lembar persetujuan anestesi.

Hasil: Berdasarkan hasil analisis terhadap 56 lembar persetujuan anestesi hasil persentase kelengkapan tertinggi pada item nama, tanggal lahir, nomor rekam medis, dan kelengkapan terendah pada item tanggal, waktu 0%.

PERPUSTAKAAN

UNIVERSITAS JENDERAL ACHMAD YANI

YOGYAKARTA

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Kesimpulan: Di RSU Mitra Paramedika anestesi masih belum lengkap dan regulasi sudah terpenuhi.

Kata Kunci: Kelengkapan lembar persetujuan anestesi.

1 Mahasiswa Perekam dan Infomasi Kesehatan Kesehatan Universitas Jenderal Achmad Yani Yogyakarta

2 Dosen Pembimbing Perekam dan Informasi Kesehatan Universitas Jenderal Achmad Yani Yogyakarta.

REVIEW OF THE COMPLETENESS OF FILLING IN THE ANESTHESIA APPROVAL SHEET FOR INPATIENTS IN III CLASS GENERAL WARD IN

QUARTER 3 AT THE PARAMEDICS PARTNER GENERAL HOSPITAL

Siti Nurrull Abibah¹, Suryo Nugroho Markus² ABSTRACT

Background: The quality of the hospital can be seen in the medical record, on of which is the level of completeness in filling out the anesthetic approva sheet. The effort is to improve the quality of a patient’s hospital being operated must be known to sign anesthesia approval there is a medical record file and hospitalization in class III general ward third quarter. Based on the results of a preliminary study that the level of completeness of filling in the anesthetic approval sheet at the paramedics general hospital still lacking in filling.

Purpose :The purpose of this study was to find out the completeness of filling in he anesthesia approval sheet at the paramedics partner general hospital.

Method research : This type of research is descriptive quantitative with cross sectional of this study were 3 as follows:1 doctor, 1 nurse, 1 head installation of medical recor. This subject is 56 sheets of anesthesia approva.

Result: Based on the results of the analysis of 56 sheets of anesthesia approva results as a percentage of identification at 20%, important reports 22%, authentication 58%, and correct documentation 0%.

PERPUSTAKAAN

UNIVERSITAS JENDERAL ACHMAD YANI

YOGYAKARTA

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Conclussions: In the general hospital paramedic partners the anethesia is sticky and regulation has been fulfilled.

Keywords: Complete sheet approval anesthesia

1 Students Medical Record and Health Information Universitas Jenderal Achmad Yani Yogyakarta

2 Lecturer Medical Record and Health Information Universitas Jenderal Achmad Yani Yogyakarta