KESESUAIAN DIAGNOSIS PADA BERKAS REKAM MEDIS DAN EHR PASIEN INSTALASI GAWAT DARURAT

Abstract

The purpose of this study is to determine the extent to which the suitability of documenting the diagnosis on the patients' file of medical record Emergency Unit with the EHR. The type of this research is descriptive study with a qualitative approach. The population in this study are 2837 patients' file of medical record Emergency Unit in RSA UGM in 2013 year and 15 doctors of Emergency Unit. The most used sample was 100 Emergency sheet forms on a data file 100 clinical manuals and documentation in the EHR. The results of this study indicates diagnosis writing between medical record file with the appropriate EHR as much as 89% and that does not suitable as much as 11%. The causes of diagnosis of nonconformities writing medical record file with the EHR are 1, no special rules governing about writing the diagnosis in the medical record file and EHR, 2. the doctor must write the diagnosis twice, 3. Writing the diagnosis in two documents (files and medical record EHR) are ineffective, 4 the term diagnosis of EHR and the term of diagnosis of ICD-10 diagnosis are difficult to equate.