Analysis Of Completeness Of Outpatient Integrated Patient Development Note Form Completion At Internal Medicine Polyclinic According To Soap At Rsud Dr. R.M. Djoelham Binjai

Yudica Rosalina; Lenni Irawati; Yusriwan Tjuanda

Yudica Rosalina Akademi Pendidikan Kesehatan Talitakum Setia Budi Street no 5-8 Simpang Selayang, Medan Tuntungan, North Sumatera, Indonesia
Lenni Irawati Akademi Pendidikan Kesehatan Talitakum Setia Budi Street no 5-8 Simpang Selayang, Medan Tuntungan, North Sumatera, Indonesia
Yusriwan Tjuanda Akademi Pendidikan Kesehatan Talitakum Setia Budi Street no 5-8 Simpang Selayang, Medan Tuntungan, North Sumatera, Indonesia

Keywords: Analysis, outpatient form, SOAP

Abstract

A method of documenting a progress patient note explicates three details, including what happened to the patient, what is planned for the patient & how the patient reacts to the therapy being taken. The documentation method employs four steps regarding a systematic decision-making process, known as SOAP which is an acronym for Subjective, Objective, Assessment, and Plan. Based on a previous study conducted at the medical record installation of Dr. R.M. Djoelham General Hospital in Binjai, there was still incomplete documentation on the forms of the patient progress notes integrated outpatient care by SOAP. Objectives: To find out the percentage of the completeness and incompleteness in filling out the outpatient integrated progress note forms according to SOAP and to determine the factors causing the completeness and incompleteness of filling out the forms according to SOAP at Dr. R.M. Djoelham General Hospital in Binjai.

Downloads

Download data is not yet available.

References

Afandi, Ahmad (2015). Analisis Kelengkapan Pengisian Formulir Catatan Terintegrasi Pasien Rawat Jalan Sesuai SOAP di RSPAU dr.S. Hardjolukito. Yogyakarta: Diploma III Rekam Medis Universitas Gadjah Mada.
Apriani, Nur F. (2017). Analisis Kelengkapan Pengisian Formulir Catatan Perkembangan Terintegrasi Pasien Rawat Inap Berdasarkan SOAP di RST Dr. Soedjono Magelang. Yogyakarta: Diploma III Rekam Medis Universitas Gadjah Mada.
Azmi, Ulul A. (2017) Standar Pendokumentasian Asuhan Terintegrasi Diruang Perawatan Interna RINRA Sayang 2 di RSUD Haji Makassar. Makassar: Fakultas Kedokteran dan Ilmu Kesehatan Universitas Islam Negeri Alauddin.
Azwar, Saifuddin (2010) Metode Penelitian. Yogyakarta: Pustaka Pelajar.
Bungin, B. (2009) Penelitian Kualitatif. Jakarta: Kencana.
Departemen Kesehatan RI, (1997) Pedoman Pengelolaan Rekam Medis Rumah Sakit di Indonesia. Jakarta: Depkes RI.
DepKes RI Dirjen YanMed. (2006). Pedoman Pengelolaan Rekam Medis Rumah Sakit di Indonesia. Jakarta: Depkes.
Emerson (dalam Arifin:2013). Tentang Manajemen.
Faste (1998). Tentang Pengertian Pelayanan Rawat Jalan.
Hatta, G. (2008) Pedoman Manajemen Informasi Kesehatan di Sarana Pelayanan Kesehatan. Jakarta: Universitas Indonesia.
Huffman Edna K. (1999). Health Information Management. Edited by Jennifer Cofer, RRA.
Miles, M.B & Huberman A.M. 1984. Analisis Data Kualitatif. Terjemahan oleh Tjetjep Rohendi Rohidi. 1992. Jakarta: Penerbit Universitas Indonesia.
Notoatmodjo, S. (2012) Metodologi Penelitian Kesehatan. Jakarta: Rineka Cipta.
Peraturan Menteri Kesehatan RI No. 269/Menkes/Per/III/2008 tentang Rekam Medis.
Peraturan Menteri Kesehatan RI No. 340/Menkes/Per/III/2010 tentang Rumah Sakit.
Presiden RI. Undang Undang RI Nomor 29 Tahun 2004 Tentang Praktik Kedokteran. Jakarta: Indonesia
Putu, Ni C. dkk (2015). Analisis Kelengkapan Rekam Medis Rawat Inap di Rumah Sakit Umum Pusat Fatmawati. Jakarta: Program Studi Kesehatan Masyarakat Universitas Indonesia.
Saryono dan Mekar Dwi A. (2013). Metodologi Penelitian Kualitatif dan Kuantitatif. Yogyakarta: Nuha Medika.
Sugiyono. (2008) Metode Penelitian Kuantitatif Kualitatif dan R&D. Bandung: CV alfabeta.
Sugiyono. (2012) Metode Penelitian Kuantitatif Kualitatif dan R&D. Bandung: Alfabeta.
Shofari, B. (1998) Pengelolaan Sistem Rekam Kesehatan. Gombong: BAPELKES.
Watson, Phyllis J. (1992). Internasional Federation of Health Record Organization. Education Commite IFHRO.