Gambaran penatalaksanaan dokumentasi read-back di ruang rawat inap paviliun umum rumah sakit siloam = description of documentation read-back in general pavilion rooms of siloam hospital.

Mairi, Patricia (2018) Gambaran penatalaksanaan dokumentasi read-back di ruang rawat inap paviliun umum rumah sakit siloam = description of documentation read-back in general pavilion rooms of siloam hospital. Bachelor thesis, Universitas Pelita Harapan.

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Abstract

Menuliskan perintah secara lengkap atau hasil pemeriksaan oleh penerima informasi; penerima membacakan kembali (read-back) perintah atau hasil pemeriksaan; dan mengkonfirmasi bahwa apa yang sudah dituliskan dan dibacakan ulang adalah akurat. Sehingga ditetapkan dalam standar VII Peraturan Menteri Kesehatan RI No 1691 2011 “Rumah sakit merencanakan dan mendesain proses manajemen informasi keselamatan pasien untuk memenuhi kebutuhan informasi internal dan eksternal serta transmisi data dan informasi harus tepat waktu dan akurat.” Oleh karena itu diperlukan mekanisme identifikasi masalah dan kendala komunikasi untuk merevisi manajemen informasi yang ada. Tujuan dari penelitian ini adalah mencari gambaran penatalaksanaan dokumentasi readback. Penelitian ini menggunakan metode deskriptif kuantitatif pendekatan studi dokumentasi, dengan teknik accidental sampling.. Penelitian ini mengambil populasi medical record pasein rawat inap lantai 2 Paviliun Umum Rumah Sakit Siloam sejumlah 274 dan sampel sejumlah 25. Instrumen penelitian ini adalah integrated note dan lembar check list read-back. Hasil penelitian menunjukkan dari 25 sampel didapati hasil 88% dilakukan dokumentasi secara lengkap dan 12% tidak lengkap. Saran untuk peneliti untuk dapat meneneliti faktor-faktor yang menghambat perawat dalam pendokumentasian telepon / Write down the complete order or results of the examination by the recipient of the information; the recipient read back the command or inspection result; and confirm that what has been written and re-read is accurate. So that the standard set out in the Regulation of the Minister of Health VII No. 1691 2011 "The hospital planning and design of patient safety information management processes to meet the needs of internal and external information as well as the transmission of data and information must be timely and accurate". Therefore we need mechanisms of problem identification and communication obstacles to revise existing information management. The purpose of this study is to find a description of the management of read-back documentation. This research uses quantitative descriptive method of documentation study approach, with accidental sampling technique. This study took the medical record population of inpatients on 2nd floor of Paviliun Umum Rumah Sakit Siloam, a population of 274 and a sample of 25. The instrument of this research is integrated note and read-back check list. The results showed that from 25 samples found 88% do the complete documentation and 12% are incomplete.

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