KELENGKAPAN REKAM MEDIK PADA PASIEN HIV/ AIDS : LITERATUR REVIEW COMPLETE MEDICAL RECORD IN HIV / AIDS PATIENTS: LITERATURE REVIEW

Sri Handayani, Ropendi Pardede, Fajrilhuda Yuniko

Abstract


ABSTRAK

 Rekam medis merupakan salah satu bagian penting dalam membantu pelaksanaan pemberian pelayanan kepada pasien. Permenkes No. 269/Menkes/Per/III/2008 tentang rekam medis, Rekam Medis adalah berkas yang berisikan catatan dan dokumen tentang identitas pasien, pemeriksaan, pengobatan tindakan dan pelayanan lain yang telah diberikan kepada pasien. Tujuan penelitian ini untuk mengatahui dan mempelajari terkait kelengkapan rekam medis pada pelayanan HIV/AIDS. Metode yang digunakan dalam penelitian ini adalah literatur review melalui telaahan jurnal dengan kriteria yaitu penelitian yang telah di publish/ diterbitkan, minimal berasal dari jurnal terakreditasi, jurnal yang berkaitan dengan rekam medis pada pasien HIV/AIDS. Data di kumpulkan dengan mereduksi informasi yang dibutuhkan dan di sajikan dalam bentuk simpulan.  Hasil penelitian Kelengkapan data rekam medik pasien HIV/AIDS masih rendah, masih banyak data yang tidaklengkap seperti no register, jenis kelamin, tanggal konfirmasi tes HIV, tempat tes, enty poin, pendidikan, status pekerjaan, dan faktor risiko. Faktor penyebab ketidak lengakapn data ini adalah dokter, konselor dan perawat kurangnya perhatian serta tanggung jawab terhadap kelengkapan setiap variable serta poin dalam rekam medis yang terlalu banyak untuk diisi. Oleh karena itu penulis menyarankan perlu adanya kordinasi antara rekam medis, POKJA/ instalasi khusus HIV, perawat dan dokter untuk melengkapi setiap variabel serta mereduksi poin – poin yang harus diisi sehingga lebeih efisien. Selain itu perlu mempertimbangkan pembuatan rekam medis electronik dengan mempertimbangan kesiapan SDM, sarana prasarana dan metode pengasawan sehingga terwujudnya kelengkapan data dan data yang berkualitas.

 

Kata Kunci : Kelengkapan Rekam Medis, HIV/AIDS

 

 

ABSTRACT


Medical records are one important part in helping the implementation of providing services to patients. Permenkes No. 269 / Menkes / Per / III / 2008 concerning medical records, Medical Records are files containing records and documents about patient identity, examinations, treatment actions and other services that have been provided to patients. The purpose of this research is to know and study the completeness of medical records related to HIV / AIDS services. The method used in this study is a literature review through the review of journals with the criteria of research that has been published / published, at least from accredited journals, journals related to medical records in HIV / AIDS patients. Data is collected by reducing the information needed and presented in the form of conclusions. Results of research Complete medical record data for HIV / AIDS patients is still low, there are still many incomplete data such as no register, gender, date of confirmation of HIV testing, test place, entry points, education, employment status, and risk factors. Factors causing the inability of this data are doctors, counselors and nurses lack of attention and responsibility for the completeness of each variable and points in the medical record that are too many to be filled. Therefore the authors suggest the need for coordination between medical records, HIV LWGs / special installations, nurses and doctors to complete each variable and reduce points to be filled so that they are more efficient. In addition it is necessary to consider making electronic medical records taking into account the readiness of human resources, infrastructure facilities and methods of volunteers so that quality data and data are realized.

Keywords: Completeness of Medical Records, HIV / AIDS


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References


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DOI: http://dx.doi.org/10.30633/jsm.v1i2.594

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