Rekam Medis: Desain, Manfaat dan Penerapannya di Praktik Bidan Mandiri Ummu Hani Yogyakarta
Abstract
Abstract
Based on observations and document studies at PMB Ummu Hani Bantul Yogyakarta, the medical record documentation system has not been optimal. PMB Ummu Hani lacks standardized medical record folders, KIB (Patient Identity Cards), and forms. For instance, postpartum records are kept in large folio paper books with batik covers, where the paper size of each form is not uniform. All healthcare personnel and facilities must maintain proper and accurate medical records to protect both patients and healthcare providers and to support the continuity of care. This study aims to design a medical record system that benefits PMB Ummu Hani. The research method used is Research and Development (RnD) with a case study approach. Data collection was conducted through observation and document review of existing medical record forms and Focus Group Discussions (FGD) with 9 midwives. The forms were designed using Canva and Epi Info applications and were tested through design presentations and a second round of FGD. The study resulted in the design of medical record folders, KIB, prenatal examination forms, delivery forms, medical procedure forms, partograph forms, postpartum forms, and child growth records. The medical record folder uses ivory paper, size F4, weighing 260 grams, cream-colored. The medical record forms use A4 paper, weighing 70 grams, white-colored, and the KIB paper size is 85.6 cm x 53.9 cm.
Keyword: design, medical record, primary care of Ummu Hani
Abstrak
Berdasarkan hasil observasi dan studi dokumen di PMB Ummu Hani Bantul Yogyakarta, sistem pencatatan dan pendokumentasian rekam medis belum berjalan optimal. PMB Ummu Hani belum memiliki map rekam medis yang standar, KIB, dan formulir yang terstandar. Contohnya, pencatatan nifas menggunakan buku besar berukuran kertas folio bergaris dengan sampul batik, di mana ukuran kertas setiap formulir tidak seragam. Setiap tenaga kesehatan dan fasilitas pelayanan kesehatan wajib menyelenggarakan rekam medis yang baik dan benar untuk memberikan perlindungan bagi pasien dan tenaga kesehatan, serta mendukung keberlanjutan pemeriksaan dan pengobatan. Penelitian ini bertujuan untuk mendesain rekam medis yang bermanfaat bagi PMB Ummu Hani. Metode penelitian yang digunakan adalah Research and Development (RnD) dengan pendekatan studi kasus. Pengumpulan data dilakukan melalui observasi dan studi dokumen pada formulir rekam medis yang ada, serta Focus Group Discussion (FGD) dengan 9 bidan. Desain formulir dibuat menggunakan aplikasi Canva dan Epi Info, kemudian diuji coba melalui presentasi hasil desain dan FGD tahap 2. Hasil penelitian menghasilkan desain map rekam medis, KIB, formulir pemeriksaan kehamilan, formulir persalinan, formulir tindakan medis, formulir patografi, formulir nifas, dan buku tumbuh kembang anak. Map rekam medis menggunakan kertas jenis ivory ukuran F4 dengan berat 260gram berwarna krem, sementara kertas formulir rekam medis berukuran A4 dengan berat 70gram berwarna putih, dan kertas KIB berukuran 85,6 cm x 53,9 cm.
Kata Kunci: desain, rekam medis, PMB Ummu Hani
Keywords
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Dewan Perwakilan Rakyat RI. Undang-Undang Republik Indonesia Nomor 17 Tahun 2023 Tentang Kesehatan. Undang-Undang. 2023;(187315):1–300.
Kementerian Kesehatan. Peraturan Menteri Kesehatan No. 24 Tahun 2022 Tentang Rekam Medis. Rekam Medis 2022 p. 2003–5.
Hillestad R, Scoville R, Taylor R. Can Electronic Medical Record Systems Transform Health Care ? Potential Health Benefits , Savings , And Costs. 2016;(November).
Muinga N, Magare S, Monda J, Kamau O, Houston S, Fraser H, et al. Implementing an open source electronic health record system in kenyan health care facilities: Case study. JMIR Med Informatics. 2018;20(4):1–13.
Joon C, Bhsc H, Nirmal M, Pt K, Farrokhyar F, Thoma A, et al. Accuracy and completeness of electronic medical records obtained from referring physicians in a Hamilton , Ontario , plastic surgery practice: A prospective feasibility study. 2015;23(1):48–50.
WHO, UNFPA. Preventing Early Pregnancy And Poor Reproductive Outcomes Among Adolescents In Developing Countries: What The Evidence Says. 2008;1–8.
Zulfita Z, Primasari EP, Syofiah PN. Analisis Kelengakapan Pendokumentasian Pelayanan Kebidanan Di Wilayah Kerja Puskesmas Lubukbuaya Kota Padang. Hum Care J. 2020;5(3):827.
Podungge Y. Asuhan Kebidanan Komprehensif. Jambura Heal Sport J. 2020;2(2):68–77.
Jannah M, Copriady J, Rasmiwetti R. Development of Interactive Learning Media using Autoplay Media Studio 8 for Colloidal Chemistry Material. J Educ Sci. 2019;3(1):132.
Ndlovu K, Mars M, Scott RE. Development of a conceptual framework for linking mHealth applications to eRecord systems in Botswana. BMC Health Serv Res. 2021;21(1):1–10.
Pal K, Dack C, Ross J, Michie S, May C, Stevenson F, et al. Digital health interventions for adults with type 2 diabetes: Qualitative study of patient perspectives on diabetes self-management education and support. J Med Internet Res. 2018;20(2).
Richesson RL, Nadkarni P. Data standards for clinical research data collection forms: Current status and challenges. J Am Med Informatics Assoc. 2011;18(3):341–6.
Sharda P, Das AK, Patel VL. Specifying design criteria for electronic medical record interface using cognitive framework. AMIA Annu Symp Proc. 2003;594–8.
Okta YA, Nisaa A, Pertiwi J. Analisis Desain Formulir Resume Medis Ditinjau Dari Aspek Fisik Isi Dan Anatomi Di Unit Rawat Inap Uptd Puskesmas Kartasura. J Manaj Inf dan Adm Kesehat. 2020;3(2):35–43.
Fajar MM, Ilmi LR, Sevtiyani I, Wicaksono B, Mardiyanti D. Optimalisasi Layanan Rawat Jalan: Desain User Interface Aplikasi Pendaftaran Online Berbasis Mobile. Indones Heal Inf Manag J. 2023;11(1):29–36.
Sagr NA Al, Sagr AN Al. The effect of electronics on the growth and development of young children : A Narrative Review. J Health Inform Dev Ctries. 2020;14(1):1–13.
Chowdhury S, Chakraborty P pratim. Universal health coverage There is more to it than meets the eye. J Fam Med Prim Care [Internet]. 2017;6(2):169–70. Available from: http://www.jfmpc.com/article.asp?issn=2249-4863;year=2017;volume=6;issue=1;spage=169;epage=170;aulast=Faizi
Widianawati E. Optimalisasi Penggunaan Ms Excel Terhadap Kepekaan Data Informasi Kesehatan Di Posyandu. J Manaj Inf Kesehat Indones. 2020;8(1):92.
Kuswari, Herniyati, Muryani, Chatarina, Nugraha S et al. The Learning Media Development Of Interactive Multimedia Based E-Learning To Improve Students’ Learning Outcome And Spatial Thinking Ability Of X Iis Students In Sma Negeri 3 Sragen In The Academic Year Of 2017/2018. GeoEco J. 2019;8(5):55.
Widyastuti HN, Wicaksono AP, Farlinda S, Rachmawati E. Sistem Informasi Peminjaman Dan Pengembalianrekam Medis Dengan Barcode Dan Notifikasi Whatsapp Di Rumah Sakit Wijaya Kusuma Lumajang. J-REMI J Rekam Med dan Inf Kesehat. 2020;1(2):61–76.
Balasopoulou A, Κokkinos P, Pagoulatos D, Plotas P, Makri OE, Georgakopoulos CD, et al. Symposium Recent advances and challenges in the management of retinoblastoma Globe ‑ saving Treatments. BMC Ophthalmol [Internet]. 2017;17(1):1. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28331284%0Ahttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC5354527%5Cnhttp://bmcpsychiatry.biomedcentral.com/articles/10.1186/1471-244X-11-49%5Cnhttp://bmcophthalmol.biomedcentral.com/articles/10.1186/s12886
Karimah RN, Setiawan D, Nurmalia PS. Rekam Medis di Rumah Sakit Balung Jember Diagnosis Code Accuracy Analysis Of Acute Gastroenteritis Disease Based on Medical Record Document in Balung Hospital Jember. 2015;2(2):12–7.
Sebagai D, Satu S, Ujian S, Memperoleh G, Ahli G, Kesehatan F, et al. Penyebab ketidaklengkapan pengisian lembar informed consent pada kasus bedah di rsud tidar kota magelang naskah publikasi. 2018;
Tweya H, Feldacker C, Gadabu OJ, Ng W, Mumba SL, Phiri D, et al. Developing a point ‑ of ‑ care electronic medical record system for TB / HIV co ‑ infected patients : experiences from Lighthouse Trust , Lilongwe , Malawi. BMC Res Notes. 2016;1–10.
Wordl Health Organization. Electronic Health Record Manual for Developing Countries. Geneva; 2006. 1–78 p.
Luthuli LP, Kalusopa T. The management of medical records in the context of service delivery in the public sector in KwaZulu-Natal, South Africa: the case of Ngwelezana hospital. South African J Libr Inf Sci. 2018;83(2):1–11.
Hazard RH, Chowdhury HR, Adair T, Ansar A, Quaiyum Rahman AM, Alam S, et al. The quality of medical death certification of cause of death in hospitals in rural Bangladesh: Impact of introducing the International Form of Medical Certificate of Cause of Death. BMC Health Serv Res. 2017 Oct 2;17(1).
DOI: https://doi.org/10.47007/inohim.v12i01.576
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