Rekam Medis: Desain, Manfaat dan Penerapannya di Praktik Bidan Mandiri Ummu Hani Yogyakarta
Authors: Ilmi Laili Rahmatul , Barokah Liberty , Zolekhah Dewi 
Published: July 2024

AbstractBased on observations and document studies at PMB Ummu Hani Bantul Yogyakarta, the medical record documentation system has not been optimal. PMB Ummu Hani lacks standardized medical record folders, KIB (Patient Identity Cards), and forms. For instance, postpartum records are kept in large folio paper books with batik covers, where the paper size of each form is not uniform. All healthcare personnel and facilities must maintain proper and accurate medical records to protect both patients and healthcare providers and to support the continuity of care. This study aims to design a medical record system that benefits PMB Ummu Hani. The research method used is Research and Development (RnD) with a case study approach. Data collection was conducted through observation and document review of existing medical record forms and Focus Group Discussions (FGD) with 9 midwives. The forms were designed using Canva and Epi Info applications and were tested through design presentations and a second round of FGD. The study resulted in the design of medical record folders, KIB, prenatal examination forms, delivery forms, medical procedure forms, partograph forms, postpartum forms, and child growth records. The medical record folder uses ivory paper, size F4, weighing 260 grams, cream-colored. The medical record forms use A4 paper, weighing 70 grams, white-colored, and the KIB paper size is 85.6 cm x 53.9 cm.Keyword: design, medical record, primary care of Ummu Hani AbstrakBerdasarkan hasil observasi dan studi dokumen di PMB Ummu Hani Bantul Yogyakarta, sistem pencatatan dan pendokumentasian rekam medis belum berjalan optimal. PMB Ummu Hani belum memiliki map rekam medis yang standar, KIB, dan formulir yang terstandar. Contohnya, pencatatan nifas menggunakan buku besar berukuran kertas folio bergaris dengan sampul batik, di mana ukuran kertas setiap formulir tidak seragam. Setiap tenaga kesehatan dan fasilitas pelayanan kesehatan wajib menyelenggarakan rekam medis yang baik dan benar untuk memberikan perlindungan bagi pasien dan tenaga kesehatan, serta mendukung keberlanjutan pemeriksaan dan pengobatan. Penelitian ini bertujuan untuk mendesain rekam medis yang bermanfaat bagi PMB Ummu Hani. Metode penelitian yang digunakan adalah Research and Development (RnD) dengan pendekatan studi kasus. Pengumpulan data dilakukan melalui observasi dan studi dokumen pada formulir rekam medis yang ada, serta Focus Group Discussion (FGD) dengan 9 bidan. Desain formulir dibuat menggunakan aplikasi Canva dan Epi Info, kemudian diuji coba melalui presentasi hasil desain dan FGD tahap 2. Hasil penelitian menghasilkan desain map rekam medis, KIB, formulir pemeriksaan kehamilan, formulir persalinan, formulir tindakan medis, formulir patografi, formulir nifas, dan buku tumbuh kembang anak. Map rekam medis menggunakan kertas jenis ivory ukuran F4 dengan berat 260gram berwarna krem, sementara kertas formulir rekam medis berukuran A4 dengan berat 70gram berwarna putih, dan kertas KIB berukuran 85,6 cm x 53,9 cm.Kata Kunci: desain, rekam medis, PMB Ummu Hani