Peningkatan Pengetahuan mengenai Analisis Kualitatif pada Rekam Medis Elektronik di Rumah Sakit Hidayah Boyolali

Abstract

Assessment of the quality of service in hospitals can be done by determining the completeness of filling in medical record documents through quantitative analysis and qualitative analysis. Qualitative analysis of medical record documents is a review of the filling in of medical records relating to consistency (consistency) which supports the contents of medical records as accurate and complete records. Meanwhile, qualitative analysis of medical record documents includes six review components, namely review of completeness and consistency of diagnosis, review of consistency of diagnosis recording, review of recording of things carried out during care and treatment, review of informed consent, review of recording techniques and review of things that cause compensation requirements. Electronic medical records are medical records created using an electronic system intended for maintaining medical records. Hidayah Boyolali Hospital has implemented electronic medical records since January 2023 in accordance with the mandate of the Republic of Indonesia Minister of Health Regulation Number 24 of 2022 concerning medical records. The place for implementing PkM is in the hall of RSU Hidayah Boyolali with the target of PkM being 13 medical records officers. The PkM method includes: (1) presentation of material by the chairman and implementing members of PkM with the theme of qualitative analysis of electronic medical records, (2) clinical qualitative analysis of inpatient medical record documents and electronic medical records of polyclinic outpatients, (3) evaluation of analysis results qualitative medical record documents for inpatients and electronic medical records for outpatient polyclinics.