Gambaran Sistem Pengelolaan Rekam Medis Di Rumah Sakit Tahun 2022

Overview of the Medical Record Management System in Hospitals in 2022

Abstract

Introduction: Medical records are those that contain information about identity, history taking, physical laboratory patient services, diagnoses, and all medical actions given to and treatment of both inpatients, outpatients, and those receiving emergency services. The purpose of this study was to find out the description of the medical record management system in hospitals.

 Methods: This type of research used descriptive research methods with a qualitative approach. In this study, in-depth interviews were conducted with 5 informants. The research was conducted at the medical record unit at the Bhayangkara Hospital at the National Police Education and Training Center. The method of data collection was by using interview, observation, and document review techniques.

Results: Based on the results of the research, the qualifications were not in accordance with the standards, the number of human resources was still lacking, the working instrument had not explained in detail the implementation of assembling as a whole, and there was no assembling soup for checking medical record files. Storage of medical record files had not been running optimally, there was often a misplacement (miss file) of medical record files and there were still multiple medical record files, and the management of medical record files for returning status files that were not in accordance with the provisions of 1x24 hours, and the filling room is narrow, Storage shelves had started to get crowded, expedition book management had not run optimally, making it difficult for officers to quickly track the whereabouts of files. And for the medical record file management system was still using the manual.

Discussion: Based on the research results, the qualifications are not up to standard, and the number of human resources is still lacking, so it is necessary to add new human resources with the D3 medical record standard Preparation of medical record files (Assembling), work instruments have not explained in detail the implementation of the assembling as a whole. The storage of medical record files at the Bhayangkara Lemdiklat POLRI Hospital has not run optimally, there are often missed file layouts (missed files) of medical record files and there are still multiple medical record files. Management of medical files for status files that did not comply with the provisions of 1x24 hours as well as narrow filling spaces, storage shelves had started to get crowded, and expedition book management had not run optimally, making it difficult for officers to quickly track the whereabouts of files. And the medical record management system still uses manuals. It is hoped that the hospital regarding medical record human resources needs to increase the number of medical record officers based on predetermined standards, namely medical record qualification standards.