Hubungan antara Pengetahuan Dokter tentang Aspek Hukum Rekam Medis dengan Penulisan Rekam Medis di Puskesmas  

Oleh:

Yani, Wisnu Murti ; Siswanto ; Suryono

Jenis: Article from Journal - ilmiah nasional
Dalam koleksi: Berkala Kesehatan Klinik vol. 15 no. 02 (Dec. 2009), page 120-124 .
Topik: medical record - law aspect - quality

Ketersediaan

Perpustakaan FK Nomor Panggil: B25.K.01 Non-tandon: 1 (dapat dipinjam: 0) Tandon: tidak ada

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Background: Medical record (MR) is the file containing notes and documents of the patient's identity, check-up, treatment, action, and other services given. MR functions primarily as the communication device of the doctors in treating the patients. The bad quality of MR (incomplete, having difficult transcription, and the writing regulation disobedience) causes the therapy process to be horrible. The obligation of writing MR in every medical practice has been arranged in law no. 29, year 2004 about Medical Practice. The rule about the writing of good MR has been arranged in the Health Minister Regulation no.269 - year 2008. The doctor's lack of knowledge in law aspect is assumed as one of the causes in poor writing of MR. Objective: This research will find out the relationship between the doctor's knowledge about law aspect of medical record with its writing, in primary health care in Sleman regency. Methods: This is a cross-sectional research where data are gained by interview using interview guide which contain the qualified questions about the law aspect of MR. The samples used in this research are all research subject, they are the entire doctors of primary health care in Sleman regency having the requirements of: 1) functional doctor; 2) still working in the central "puskesmas" when the research is conducted; and 3) willing to be the subject of research. Result and Conclusion: The research resulted in 60 data of doctors' knowledge in law aspect of MR and 60 data about quality of the MR. The mean value of doctor's knowledge about law aspect of MR is 63% from the ideal value of knowledge that every doctor must have. The mean value of quality of MR is 69% from the ideal value that requirement based on Health Minister Regulation no.269 - year 2008. Level of quality of medical record in primary cares in Sleman district among doctors who have good level of knowledge of law aspect of medical record is significantly lower (36.8%) than those who have bad level of knowledge of law aspect of medical record (81.8%) (p = 0.0012). Bad level of knowledge of doctors in primary care in Sleman district associated with approximately 7 times result in development of bad quality of medical records if it is compared those who have good level of knowledge about law aspect of medical record.

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