Analisis Kebijakan Tatakelola Rekam Medis Pada Instalasi Rawat Jalan

Policy Analysis of Medical Record Management in Outpatient Installation

Abstract

Introduction: The organization of medical records in a health institution, both hospitals, clinics or health centers is needed as a health service facility and is an organization that must be regulated in such a way as to achieve the goals that have been set.

Methods: The research method used was a qualitative research method with data collection techniques, triangulation of data sources, and methods in the form of semi-structured interviews and structured observations. The informants in this study were 4 main informants consisting of the Medical Record Staff of the Assembling, coding, indexing, and filling sections, and 1 key informant, namely the head of the medical record. In this study, researchers used the process of data analysis before the field and during the Spradley model in the field. Where the model taken was a componential analysis.

Results: The results of the study were the policies used in the implementation of medical record management the Decree of the Director of the Pasar Minggu Regional General Hospital, the Special Capital Region of Jakarta Number 488 of 2018, and the Minister of Health Regulation 269 of 2008. The policy discussed the rules and SOPs in the implementation of recording activities. medical. Details of the activities included in the installation of medical records are registration, assembling, coding, indexing, and filing. The problem that occurred in these activities was that in the patient registration section there was a double RM (Medical Record) because of the double registration of patients, in the assembling section it was found that there were still incomplete filling of medical records, in the coding section the problem was related to the unclear writing of the doctor on the diagnosis of the patient's disease, in the implementation of indexing there are no problems, and in the filling section, there is an error in the placement of the file due to the negligence of the officer.

Discussion: It is expected that the medical record officer will re-monitor the completeness of the contents of the medical record and cooperate with doctors, nurses, and other health workers to complete the contents of the medical record.