Gambaran Kelengkapan Dokumentasi Assessment Pra Induksi di Rumah Sakit Jatiwinangun
DOI:
https://doi.org/10.56338/jks.v9i8.11911Keywords:
Kata Kunci: Assessment Pra Induksi; Dokumentasi Anestesi; Kelengkapan Rekam Medis, Keywords: Pre-Induction Assessment; Anesthesia Documentation; Completeness Of Medical RecordsAbstract
ABSTRAK
Assessment pra induksi merupakan tahapan penting sebelum tindakan anestesi dan pembedahan untuk memastikan kondisi pasien serta meminimalkan risiko komplikasi perioperatif. Dokumentasi assessment pra induksi yang lengkap berfungsi sebagai sumber informasi medis, sarana komunikasi antar tenaga kesehatan, serta bukti pelayanan kesehatan. Dalam pelaksanaannya kelengkapan dokumentasi masih belum memenuhi standar 100% sesuai Standar Pelayanan Minimal (SPM) rumah sakit. Penelitian ini bertujuan untuk mengetahui gambaran kelengkapan dokumentasi assessment pra induksi di Rumah Sakit Jatiwinangun. Penelitian ini menggunakan metode deskriptif kuantitatif dengan pendekatan retrospektif. Data dikumpulkan melalui observasi terhadap 106 dokumen rekam medis pasien anestesi umum periode Juli–Agustus 2025 menggunakan teknik total sampling. Analisis data dilakukan secara univariat dalam bentuk distribusi frekuensi dan persentase. Hasil penelitian menunjukkan bahwa sebagian besar dokumen berasal dari pembedahan elektif sebanyak 96 dokumen (90,6%), sedangkan pembedahan cito sebanyak 10 dokumen (9,4%). Pada pembedahan elektif, tingkat kelengkapan dokumentasi assessment pra induksi sebesar 54% dan ketidaklengkapan sebesar 46%. Sementara pada pembedahan cito, tingkat kelengkapan dokumentasi sebesar 40% dan ketidaklengkapan sebesar 60%. Hal ini menunjukkan bahwa tingkat kelengkapan dokumentasi assessment pra induksi pada pembedahan cito lebih rendah dibandingkan dengan pembedahan elektif. Secara keseluruhan, kelengkapan dokumentasi assessment pra induksi belum mencapai standar 100% sesuai dengan Standar Pelayanan Minimal (SPM) Rumah Sakit.
ABSTRACT
Pre-induction assessment is a crucial step before anesthesia and surgery to ensure patient condition and minimize the risk of perioperative complications. Complete pre-induction assessment documentation serves as a source of medical information, a means of communication between healthcare professionals, and evidence of healthcare services. In practice, the completeness of documentation still does not meet 100% standards according to the hospital's Minimum Service Standards (SPM). This study aims to determine the completeness of pre-induction assessment documentation at Jatiwinangun Hospital. This study used a quantitative descriptive method with a retrospective approach. Data were collected through observation of 106 medical records of general anesthesia patients from July to August 2025 using a total sampling technique. Data analysis was performed univariately in the form of frequency distribution and percentage. The results showed that the majority of documents came from elective surgery (96 documents (90.6%)), while 10 documents came from emergency surgery (9.4%). In elective surgery, the completeness of pre-induction assessment documentation was 54% and incompleteness was 46%. Meanwhile, in emergency surgery, the completeness of documentation was 40% and incompleteness was 60%. This indicates that the level of completeness of pre-induction assessment documentation in emergency surgery is lower than in elective surgery. Overall, the completeness of pre-induction assessment documentation has not reached 100%, as per the Hospital Minimum Service Standards (SPM).
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