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Abstract
Abstrak
Pelayanan yang diberikan kepada pasien di rumah sakit tidak terlepas dari risiko terjadinya kesalahan yang dapat mempengaruhi keselamatan pasien. Permasalahan yang umumnya terjadi di fasilitas pelayanan kesehatan di Kota Gorontalo yaitu seperti ketidaklengkapan berkas rekam medis disebabkan ketidakdisiplinan dokter dalam pengisian riwayat perawatan pasien, akses informasi rekam medis yang tidak tepat akibat kesalahan identifikasi pasien, serta kesalahan coding diagnosa pasien yang menyebabkam sulitnya klaim serta pembiayaan pelayanan yang tidak sesuai. Penelitian bertujuan menganalisis tingkat kemapanan implementasi manajemen risiko rekam medis di rumah sakit kota Gorontalo. Jenis penelitian adalah kuantitatif deskriptif. Populasinya yaitu seluruh rumah sakit yang ada di Kota Gorontalo. Pemilihan sampel secara non probability sampling yaitu mewakili keseluruhan faktor struktural organisasi rumah sakit yang meliputi kelas rumah sakit, status kepemilikan rumah sakit, dan jenis rumah sakit. Implementasi manajemen risiko di Rumah Sakit Kota Gorontalo diperoleh dokumentasi memiliki implementasi yang rendah hampir di semua rumah sakit sampel (60-66,67%), sedangkan Pelatihan/Pendidikan Berkelanjutan tergolong memiliki implementasi yang cukup tinggi. 4 dari 5 rumah sakit berada di tahap 4 (aksi) sedangkan 1 rumah sakit berada di tahap 2 (kontemplasi). Untuk mencapai tingkat kemapanan yang lebih baik dalam implementasi manajemen risiko sangat diperlukan komitmen dari seluruh bagian organisasi dalam rumah sakit.
Abstract
The services provided to patients in the hospital cannot be separated from the risk of errors that can affect patient safety. The problems that generally occur in health service facilities in Gorontalo City, such as incomplete medical record files due to doctors' indiscipline in filling in patient care history, access to incorrect medical record information due to patient identification errors, as well as patient diagnosis coding errors that cause difficulty claims and service financing. that doesn't fit. This study aims to analyze the level of the implementation of risk management medical records in Gorontalo city hospitals. This type of research is descriptive quantitative. The population is hospitals in Gorontalo City. The sample was selected by non-probability sampling, which represents the overall structural factors of the hospital organization including class of hospital, ownership status of the hospital, and type of hospital. The implementation of risk management in Gorontalo City Hospital shows that documentation has a low implementation in almost all sample hospitals (60-66.67%), while Continuing Training / Education is classified as having a fairly high implementation. 4 out of 5 hospitals at stage 4 (action) while 1 hospital at stage 2 (contemplation). To achieve a better level of risk management implementation requires commitment from all levels of the organization in the hospital.
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