CLINICAL AUDIT OF MEDICAL RECORDS BASED ON CLINICAL PATHWAY: CASE STUDY BENIGN PROSTATIC HYPERPLASIA (BPH)

Ida Sugiarti; Dedi Setiadi; Fadil Ahmad Junaedi; Ida Wahyuni

doi:10.34011/jmp2k.v36i1.3436

Authors

Ida Sugiarti Poltekkes Kemenkes Tasikmalaya, Tasikmalaya, Indonesia
Dedi Setiadi Poltekkes Kemenkes Tasikmalaya, Tasikmalaya, Indonesia
Fadil Ahmad Junaedi Universitas Bhakti Tunas Husada, Tasikmalaya, Indonesia
Ida Wahyuni Poltekkes Kemenkes Tasikmalaya, Tasikmalaya, Indonesia

DOI:

https://doi.org/10.34011/jmp2k.v36i1.3436

Keywords:

audit klinis, BPH, jalur klinis, rekam medis

Abstract

Benign Prostatic Hyperplasia (BPH) merupakan kondisi umum pada pria dewasa dengan prevalensi melebihi 50 % pada usia ≥ 60 tahun. BPH menimbulkan gejala lower urinary tract infection yang menurunkan kualitas hidup serta meningkatkan beban layanan kesehatan melalui kunjungan, pemeriksaan, dan intervensi medis. Praktik pelayanan BPH masih bervariasi antar layanan kesehatan, rekam medis yang masih tidak konsisten dan sering menyimpang dari pedoman klinis. Tujuan penelitian mengkaji implementasi clinical pathway (CP) BPH melalui audit klinis serta mengeksplorasi faktor‑faktor penghambatnya. Jenis penelitian kualitatif dengan desain studi kasus pada satu pusat layanan rujukan daerah. Data dikumpulkan melalui tiga sumber triangulasi: (1) observasi audit medis terhadap 63 rekam medis pasien BPH, (2) wawancara mendalam dengan 12 tenaga kesehatan (dokter dan perawat), dan (3) dokumen kebijakan terkait CP. Analisis tematik dilakukan secara iteratif untuk mengidentifikasi pola‑pola ketidaksesuaian CP serta hambatan implementasi. Hasil penelitian sebanyak 35 % rekam medis tidak memenuhi kriteria CP. Hambatan utama meliputi rendahnya kesadaran tenaga kesehatan terhadap CP, keterbatasan waktu klinis, serta kurangnya integrasi sistem informasi kesehatan. Implementasi CP BPH masih terhambat oleh faktor klinis dan sistemik. CP berbasis bukti menawarkan solusi strategis untuk meningkatkan konsistensi dan kualitas layanan. Diperlukan kebijakan pendukung, pelatihan berkelanjutan, dan integrasi sistem informasi untuk mengoptimalkan penerapannya

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