Evaluasi Penggunaan Simbol dan Singkatan Pada Rekam Medis Berdasarkan SOP Di Puskesmas Giriwoyo 2 - 2152200009

RISMA MARETA MAHARANI, 2152200009 Evaluation of the Use of Symbols and Abbreviations in Medical Records Based on Sop at the Giriwoyo Health Center 2. Scientific Writing. DIII Medical Records and Health Information. Faculty of Public Health and Health Sciences. Veteran Bangun Nusantara University 2024.
The symbols and abbreviations included in the SNARS Edition 1.1 standard are found in the hospital management standards group, namely Medical Record Information Management (MIRM 12), symbols in medical records are manifested in images, shapes, movements, which represent an idea. An abbreviation is an abbreviation or summary of a sentence or word. Abbreviations are often used to abbreviate a person's name, greeting, title or unit of measurement in a sentence. The use of symbols and abbreviations is regulated in law and there are supporting SOPs in each health facility. Based on a preliminary study conducted at the Giriwoyo 2 Community Health Center, there were problems related to the use of symbols and abbreviations, therefore an evaluation needed to be carried out. This research aims to evaluate the use of symbols and abbreviations. The research method is a mix method population in this study using outpatient medical record files with a large sample of 90 outpatient medical record files in 2022. The research instrument uses document study guidelines with checklist methods and interview guidelines. The results of research with a sample of 90 outpatient medical record documents using a checklist sheet showed that 57% of the symbols used were correct, 20% were incorrect and 23% should not be used. The data obtained from the use of abbreviations is 65% correct, 30% incorrect and 5% should not be used. Conclusion: Giriwoyo 2 Community Health Center already has SOP guidelines for writing symbols and abbreviations, but its implementation has not been optimal because there are influencing factors, namely too short a time and writing errors in patient diagnoses.

Keywords: Medical Record Files, Outpatient, Symbols and Abbreviations.