Kepatuhan Dokter dalam Pengisian Rekam Medis di Indonesia: Sebuah Telaah Sistematis
DOI: 10.29241/jmk.v10i1.1889Author
Inneke Elysia Lavender(1*)(1) Diponegoro University
(1*) Corresponding Author
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Abstract
Pendahuluan. Rekam medis merupakan suatu kumpulan catatan dan informasi lengkap terkait riwayat kesehatan pasien. Akan tetapi, di Indonesia sendiri masih banyak ditemukan rekam medis yang tidak terisi dengan baik dan benar. Tujuan penelitian ini adalah untuk mengidentifikasi faktor yang mempengaruhi kepatuhan tenaga kesehatan dalam pengisian rekam medis di Indonesia. Metode Penelitian. Penelitian ini menggunakan systematic review dengan pencarian artikel yang dilakukan selama 2 minggu (Juni-Juli 2023). Proses penelusuran artikel melalui database jurnal yang meliputi: PubMed, ScienceDirect, Google Scholar dan Portal Garuda. Kriteria inklusi pada penelitian ini adalah artikel full paper dengan metode penelitian belah lintang dengan tahun artikel dipublish tahun 2017-2023. Hasil Penelitian. Hasil yang ditemukan pada sintesis data primer adalah ketidakpatuhan dokter dalam pengisian rekam medis yakni memiliki rata-rata 79,5%. Rata-rata penyebab dokter tidak patuh dalam pengisian rekam medis adalah dikarenakan pengetahuan, komitmen, sikap, motivasi, beban kerja yang tinggi, tempat kerja yang tidak nyaman, insentif yang rendah dan faktor sosiodemografi. Kesimpulan. Faktor yang mempengaruhi ketidakpatuhan dalam pengisian rekam medis rata-rata disebabkan oleh pengetahuan, komitmen, sikap, motivasi dan beban kerja yang tinggi.
Introduction: Medical records are comprehensive documents that contain detailed information pertaining to a patient's medical background. However, in Indonesia, many medical records are still need to be filled properly and correctly. The objective of this study was to ascertain the determinants that impact physician compliance to completing medical records in Indonesia.
Research Methods. This study used a systematic review research. The process of finding primary studies was done for two weeks (June-July 2023) through journal databases, including PubMed, ScienceDirect, Google Scholar, and Garuda. The inclusion criteria for this study include full-text studies applying a cross-sectional research design, published between 2017 and 2023.
Results. Physician noncompliance in filling up medical records, with an average of 79.5%, was discovered in the synthesis of primary data. The average causes of doctors' noncompliance in filling out medical records are knowledge, commitment, attitude, motivation, workload, uncomfortable workplace, low incentives and sociodemographic factors.
Conclusion. The lack of compliance among physicians in documenting medical records can be attributed to factors such as limited knowledge, poor commitment, negative attitudes, low motivation, and high workload.
Keywords
References
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