Evaluasi Penyelenggaraan Rekam Medis dalam Pemenuhan Standar Akreditasi di Puskesmas Kedaung Barat Kabupaten Tangerang

Abstract Implementation of medical record services based on accreditation standards would improve the quality and safety of patients at Public Health Center . Public Health Center accreditation must be carried out so that the optimization of its functions could run optimally, both in terms of service performance and the resources used. Objectives clicking this study was to evaluate the implementation of medical records service in meeting the standard 8.4 at chapter IV accreditation standard at Kedaung Barat Public Health Center, Tangerang District. This standard had 4 criterias and 13 assessment elements. This research was a quantitative research with descriptive methods. The population of this study were all medical record files that were available at the time of the study. The data source is primary adn secondary data with a total sample of 30 taken by simple random sampling. The results of the study were 3 elements of assessment that were fully achieved (23.1%), 3 elements of assessment were partially achieved (23.1%) and 7 elements of assessment that were not achieved (53.8%). The total score obtained was 45 out of 130 (34.6%). Conclusion: the implementation of medical records based on the accreditation standard of 8.4 in Kedaung Public Health Cente has only been partially fulfilled, and needs to be improved until 100% fulfillmentKeyword: Medical Records, Public Health Center, Accreditation StandardsAbstrakPelayanan rekam medis berdasarkan standar akreditasi akan meningkatkan mutu dan keselamatan pasien di puskesmas. Akreditasi puskesmas wajib dijalankan agar optimalisasi fungsi puskesmas dapat berjalan secara optimal, baik dari kinerja pelayanan maupuan sumber daya yang digunakan. Tujuan penelitian ini adalah melakukan evaluasi penyelenggaraan rekam medis berdasarkan standar akreditasi bab IV standar 8.4 di Puskesmas Kedaung Barat Kabupaten Tangerang. Standar ini memiliki 4 kriteria dan 13 elemen penilaian Jenis penelitian ini adalah penelitian kuantitatif dengan metode deskriptif. Populasi penelitian ini adalah seluruh berkas rekam medis yang ada saat waktu penelitian. Sumber data merupakan data primer dan sekunder dengan jumlah sampel 30 yang diambil dengan cara simple random sampling. Hasil dari penelitian ini adalah terdapat 3 elemen penliaian yang tercapai penuh (23,1%), 3 elemen penilaian tercapai sebagian (23,1%) dan 7 elemen penilaian yang tidak tercapai (53,8%). Total skor yang didapat adalah 45 dari 130 (34,6%). Kesimpulan: penyelenggaraan rekam medis berdasarkan standar akreditasi 8.4 di Puskesmas Kedaung baru terpenuhi sebagian, dan perlu ditingkatkan lagi agar terpenuhi 100%.Kata Kunci: Rekam medis, Puskesmas, Standar akreditasi