2020年,印尼工人Covid-19 RSU Imelda的医疗记录回顾

Mei Sryendang Sitorus, Esraida Simanjuntak, Valentina Valentina
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引用次数: 0

摘要

定量分析是对病历内容的某些部分进行审查,以发现不足之处,特别是与病历文件编制有关的不足之处。冠状病毒病2019 (Covid-19)是一种由严重急性呼吸综合征冠状病毒2 (SARSCoV-2)引起的传染病。本研究的目的是了解2020年印度尼西亚伊梅尔达佩克贾RSU隔离室患者病历文件审查的实施情况。人群是2020年在新冠肺炎隔离室接受治疗的所有患者多达182人,研究样本是10月份在新冠肺炎隔离室接受治疗的所有患者多达48人。DRM审查在四个变量上进行。从研究结果中得出,对合适DRM的时效性进行评审的比例高达35.41%;审核准确Opname Warrant Form (SPO)填写DRM的准确率31.25%,正确IGD Assessment Form填写DRM的准确率52.08%,正确Medical Resume Form填写DRM的准确率100%,正确Observation Form填写DRM的准确率66.67%;Opname Warrant Form (SPO)的DRM可读性审核(100%)、IGD Assessment Form(77.08%)、Medical Resume Form(100%)、Observation Form (72.92%);68.75%的文件发现Drm完整性审查筛选表,77.08%的文件发现分诊表,89.58%的文件发现内部转移表,81.25%的文件发现出院计划表。一般同意表、住院病人评估表、CPPT表、观察表以及信息和教育表均可在100%的文件中找到。建议现有的SPO社会化优先考虑填写医疗记录的准确性,而不仅仅局限于表格的完整性。
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Review Rekam Medis Pasien Ruang Isolasi Covid-19 RSU Imelda Pekerja Indonesia Tahun 2020
Quantitative Analysis is a review of certain parts of the contents of medical records to find deficiencies, especially those related to the documenting of medical records. Coronavirus Disease 2019 (Covid-19) is an infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARSCoV-2). The purpose of this study is to find out the implementation of the Covid-19 Isolation Room Patient Medical Record Document Review at RSU Imelda Pekerja Indonesia in 2020. The population is all patients treated in the Covid-19 Isolation Room in 2020 as many as 182 people, the study sample is all patients treated in the Covid-19 Isolation Room in October as many as 48 people. The DRM review was conducted on four variables. From the results of the study obtained that the Review of Timeliness of appropriate DRM Returns as much as 35.41%; Review of the Accuracy of Filling out DRM for the exact Opname Warrant Form (SPO) 31.25%, the appropriate IGD Assessment Form 52.08%, the right Medical Resume Form 100%, and the proper Observation Form 66.67%; DRM Readability Review for Opname Warrant Form (SPO) which reads 100%, IGD Assessment Form that reads 77.08%, Medical Resume Form that reads 100%, and Observation Form that reads 72.92%; Drm Completeness Review for Screening Form found in 68.75% of documents, Triage Form found in 77.08% documents, Internal Transfer Form found on 89.58% of documents, Discharge Planning Form found on 81.25% of documents.For General Consent Forms, Inpatient Assessments, CPPT Forms, Observation Forms, and Information and Education Forms are found in all documents that are 100%. It is recommended that the existing SPO socialization prioritizes the accuracy of filling out medical records qualitatively, not limited to the completeness of the form only.
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