Quality Assurance (QA) Rekam Medis

- Quantitative analysis dr. Rano Indradi S, M.Kes

Health Information Management Consultant
Website
: www.ranocenter.net
Facebook profile : www.facebook.com/ranocenter
Facebook group : www.tinyurl.com/ranocenter
Email
: rano@ranocenter.net /
rano_is@yahoo.com
Hp
: 0856 266 1617

Health Record Entry Documentation

Identify the patient: name & number on all new pages
added to the chart.
Identify the author: signed w/ an initial, last name, and
credentials.
Documents only the authors care: never anyone
elses.
Uses the proper form or view: it aids communications
by structuring the chart.
Complete all item: to ensure completion of all content.
Include date & time: to relate observations/ activities
to each other.

Health Record Entry Documentation

Are concise: recording all necessary information and
nothing else. Avoids meaningless phrases, the word
patient and complete sentences.
Spell correctly, use standard terms and symbols.
Abbreviations: use only approved and safe
abbreviations
Are specific: record patient behavior and complaints in
specific terms.
Are exact: noting time, effect, and results of all
procedures, avoiding ditto marks.
Are timely: recorded shortly after, and never before,
completing patient care.

Health Record Entry Documentation

Paper-based records:
Are legible: ensuring that other members of the care team can read
the entries.
Use black ink: ensures the best photocopies, faxes, and document
imaging.
Leave no blank lines: draw a line through the center of an empty
line to present charting by someone else in the area signed.
Chart omissions as a new entry: never backdate or add to prior
entries.
Never obscure entries: draw a line throgh any mistake and write
error or mistake entry above it. Erasures, white out, and heavy
mark outs create doubt when the record is needed by other users.

Quality Assessment & Improvement

Study of Patient Record Documentation

The purpose is not to obtain data

retrospectively but to monitor the adequacy
of current systems and to make changes in the
information system when needed.
Types:
Quantitative analysis
Qualitative analysis
Legal analysis

Quantitative Analysis
Patient ID on every paper form (front and back) and
screen is correct.
All necessary authorization or consents are present and
signed or authenticated by the patient or legal
representative, including those for general agreement,
specific procedures, photographs, experimental
treatment, advance directives, and autopsy.
Documented principal dx on discharge, secondary dx,
and procedure are present in the appropriate form or
location within the record. This information is completed
and authenticated by the physician or autorized clinician.

Quantitative Analysis
Discharge summary is present, when required, and
authenticated.
H&P are present, documented within the time frame
required by appropriate regulations, and
authenticated as appropriate.
Consultation report is present and authenticated
when a consultation request appears in the listing of
physician or practitioner orders.

Quantitative Analysis
All diagnostic tests ordered by the physician or
practitioner are present and authenticated by
comparing physician orders, financial bill, and the
test reports documented in the patients health
record.
An admiting progress note, a discharge progress
note, and an appropriate number of notes
(frequency depends on the type of case or health
care agency) documented by physicians or clinicians
throughout the patients care process are present.

Quantitative Analysis
Each physician or practitioner order entered into the
record is authenticated. An admitting and a discharge
physician or practitioner order are present. Orders are
present for all consultations, diagnostic tests, and
procedures when these reports are found in the
record.
Operative, procedure, or therapy reports are present
and authenticated when orders, consent forms, or
other documentation in the record indicates that they
were performed.
A pathology report is present and authenticated when
the operative report indicates that tissue was
removed.

Quantitative Analysis
Preoperative, operative, and postoperative anesthesia
reports are present and authenticated.
Nursing or ancillary health professionals reports and
notes are present and authenticated.
Reports required for patients treated in specialized
units, such as those for patients receiving care in the
obstetrics unit, neonatal nursery, or mental health or
rehabilitation units, are present and authenticated.
Preliminary and final autopsy reports on patients who
have died at the facility are present and authenticated.

Ringkasan
Apa yang sudah tertulis/ terekam diantara
kita, janganlah hilang begitu saja.
Pahami:
anatomi & fisiologi,
patologi,
TM,
formulir RM, alur prosedur pelayanan,
kebijakan & hukum kesehatan,
daftar singkatan & simbol yang berlaku,

Langkah Analisis Kuantitatif

RanoCenter

12

4 Aspek Analisis Kuantitatif

Review Identifikasi
Review Otentikasi
Review Pelaporan yang diperlukan
Review Pencatatan

Selanjutnya
Pahami prosedur pelengkapan RM yang
belum lengkap
Perhatikan batas waktu pelengkapan RM
Hitung, laporkan, dan tindak lanjuti:
Incomplete MR rate
Delinquent MR rate

Terima kasih
Be professional !
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