Kepatuhan Dokter dalam Pengisian Rekam Medis di Indonesia: Sebuah Telaah Sistematis

DOI: 10.29241/jmk.v10i1.1889

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Inneke Elysia Lavender(1),
(1) Diponegoro University
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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

Physician, medical records, compliance

References

Ahmed, M. F., Galfo, A., Huggins, W., Paddock, L. E., Stroup, A. M., & Malhotra, J. (2021). Challenges of Medical Record Abstraction in a Long-Term Follow-up Study. Journal of Registry Management, 48(3), 88.

Anisafitri, A. (2019). Hubungan Karakteristik Dokter Penanggung Jawab Pelayanan (DPJP) terhadap Kepatuhan Pengisian Resume Medis Pasien Badan Penyelenggara Jaminan Sosial Kesehatan (BPJS) (Studi di Instalasi Rawat Inap Rumah Sakit Islam Jemursari Surabaya). The Indonesian Journal of Public Health, 14(1), 1–12. https://doi.org/10.20473/ijph.vl14il.2019.1-12

Ball, J. E., Bruyneel, L., Aiken, L. H., Sermeus, W., Sloane, D. M., Rafferty, A. M., Lindqvist, R., Tishelman, C., & Griffiths, P. (2018). Post-operative mortality, missed care and nurse staffing in nine countries: A cross-sectional study. International Journal of Nursing Studies, 78, 10–15. https://doi.org/10.1016/j.ijnurstu.2017.08.004

Fishbein, D., Nambiar, S., McKenzie, K., Mayorga, M., Miller, K., Tran, K., Schubel, L., Agor, J., Kim, T., & Capan, M. (2020). Objective measures of workload in healthcare: a narrative review. International Journal of Health Care Quality Assurance, 33(1), 1–17. https://doi.org/10.1108/IJHCQA-12-2018-0288

Giyatno, & Megawati. (2021). Pengaruh Faktor Predisposisi, Faktor Pendorong Dan Faktor Pendukung Terhadap Pencatatan Rekam Medis di RSUD Dr. RM Djoelham Binjai. Jurnal Ilmiah Perekam Dan Informasi Kesehatan Imelda (JIPIKI), 6(2), 161–173. https://doi.org/10.52943/jipiki.v6i2.578

Gressgård, L. J. (2014). Knowledge management and safety compliance in a high-risk distributed organizational system. Safety and Health at Work, 5(2), 53–59. https://doi.org/10.1016/j.shaw.2014.03.002

Husni, M. (2018). Pengaruh Pengetahuan, Sikap dan Motivasi Terhadap Kepatuhan Dokter dalam Penulisan Diagnosis pada Resume Medis di RS Zahirah 2018. Jurnal Administrasi Rumah Sakit Indonesia, 4(3), 184–197. https://doi.org/10.7454/arsi.v4i3.2623

Indrawan, D. (2017). Faktor-Faktor Yang Mempengaruhi Kepatuhan Dokter Dalam Mengisi Rekam Medis Di Unit Rawat Inap Rumah Sakit Wava Husada. Journal of Islamic Medicine, 1(2), 55–66. https://doi.org/10.18860/jim.v1i2.4454

Kencana, G., Rumengan, G., & Hutapea, F. (2019). Analysis of Medical Record Filling Completeness At Inpatient Care Facilitiy of X Hospital. Jurnal Manajemen Kesehatan Yayasan RS. Dr. Soetomo, 5(1), 27–37.

Larasugiharti, T.-. (2023). Persiapan Integrasi Sistem Rekam Medis Manual ke Sistem Rekam Medis Elektronik di RS Puri Asih Karawang. Jurnal Manajemen Kesehatan Yayasan RS.Dr. Soetomo, 9(2), 2019. https://doi.org/10.29241/jmk.v9i2.1433

Lestari, A. I., Ruswanti, E., & Hilmy, M. R. (2020). The Medical Doctor Knowledge, Medical Resume, BPJS Claim Process, and Doctor Compliance Behavior to Filling a Medical Resume At X Hospital Jatinegara. Journal of Multidisciplinary Academic, 4(5), 308–312. http://kemalapublisher.com/index.php/JoMA/article/view/492

Management, C. for E.-B. (2019). Critical Appraisal of Belah Lintang Study (Survey). https://cebma.org

Mukhlis, M. (2020). Faktor-Faktor yang Berhubungan dengan Kelengkapan Dokumen Rekam Medis di Ruang Rawat Inap Rumah Sakit Cut Meutia Langsa. Jurnal Edukes : Jurnal Penelitian Edukasi Kesehatan, 3, 118–126.

Nisa, A. S. (2018). The Differences of Doctor Adherence and Medical Record Completeness in Accredited and Unaccredited Primary Health Care. Jurnal Medicoeticolegal Dan Manajemen Rumah Sakit, 7(April), 33–42. https://doi.org/10.18196/jmmr.7154

North Carolina University. (2019). Prisma Flow Diagram 2020. Https://Guides.Lib.Unc.Edu/Prisma. https://guides.lib.unc.edu/prisma

Undang-Undang Republik Indonesia Nomor 36 Tahun 2009 Tentang Kesehatan, (2009).

Ratnawati, R. (2020). Analysis The Level of Compliance of Hospital Human Resources in Writing The Status of Inpatient Medical Record Dr Sayidiman Hospital and The Influences Factors. Journal for Quality in Public Health, 3(2), 423–433. https://doi.org/10.30994/jqph.v3i2.92

Simanjuntak, M. (2018). Tinjauan Kepatuhan Dokter Dalam Pengisian Dokumen Rekam Medis Rawat Inap di Sakit Umum Imelda Pekerja Indonesia (RSU IPI) Medan Tahun 2018. Jurnal Ilmiah Perekam Dan Informasi Kesehatan Imelda, 3(2), 518–523.

Tubaishat, A. (2019). The effect of electronic health records on patient safety: A qualitative exploratory study. Informatics for Health and Social Care, 1(44), 79–91.

Utmawati, E., Kusumapradja, R., & Mustikawati, I. S. (2023). The Effect of Knowledge, Attitudes and Commitment of Doctors on the Completeness of Inpatient Medical Resume Completion at Krakatau Medika Hospital Cilegon Banten. Asian Journal of Healthy and Science, 2(3), 119–129.

Veenstra, G. L., Dabekaussen, K. F. A. A., Molleman, E., Heineman, E., & Welker, G. A. (2022). Health care professionals’ motivation, their behaviors, and the quality of hospital care: A mixed-methods systematic review. Health Care Management Review, 47(2), 155–167. https://doi.org/10.1097/HMR.0000000000000284

Weske, U., Boselie, P., van Rensen, E., & Schneider, M. (2019). Physician compliance with quality and patient safety regulations: The role of perceived enforcement approaches and commitment. Health Services Management Research, 32(2), 103–112. https://doi.org/10.1177/0951484818813324

White, B. P., Willmott, L., Cartwright, C., Parker, M., Williams, G., & Davis, J. (2017). Comparing doctors’ legal compliance across three Australian states for decisions whether to withhold or withdraw life-sustaining medical treatment: Does different law lead to different decisions? BMC Palliative Care, 16(1), 1–8. https://doi.org/10.1186/s12904-017-0249-1

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