scholarly journals Tinjauan Pelaksanaan Sistem Penyimpanan Rekam Medis Berdasarkan Standar Akreditasi Di UPTD Puskesmas Kotanopan Mandailing Natal

2021 ◽  
Vol 6 (1) ◽  
pp. 14-22
Author(s):  
Zulham Andi Ritonga ◽  
Hasran Ependi Lubis
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Storage System ◽  
Patient Medical Record ◽  
Biological Damage ◽  
Descriptive Research ◽  
Accreditation Standards ◽  
File Storage ◽  
Speed Up ◽  
Storage Racks

Storage of medical records is one of the assessments in puskesmas accreditation standards. The medical record file storage system is very important to do in health care institutions, because the storage system can make it easier for medical record files to be stored in storage racks, speed up the recovery or retrieval of medical record files stored on storage racks, easy to return, and protect record files. from theft, physical, chemical and biological damage. The purpose of this study was to determine how the implementation of a medical record storage system based on puskesmas accreditation standards, which was carried out in August 2020. The research method used was descriptive research with a qualitative approach. The number of research informants was 4 people. Storage of medical records had not used tracers and expedition book as a means of replacing medical record files and notes in and out of borrowed medical record files. Meanwhile, tracer and expedition books can assist officers in searching for missing / out of place medical record files. This can hamper the provision of patient medical record files that are needed. It is hoped that the UPTD Puskesmas Kotanopan will provide regular training or debriefing to medical record officers

scholarly journals ANALISIS LUAS RUANGAN BERDASARKAN KEBUTUHAN RAK DI RUANG PENYIMPANAN BERKAS REKAM MEDIS RAWAT JALAN DI RUMAH SAKIT UMUM MADANI MEDAN TAHUN 2019

2020 ◽  
Vol 5 (1) ◽  
pp. 20-29
Author(s):  
Puput Melati Hutauruk ◽  
Fince Rahmat Zega
Keyword(s):  
General Hospital ◽  
Medical Record ◽  
Medical Records ◽  
Patient Medical Record ◽  
File Storage ◽  
Storage Room ◽  
Quantitative Descriptive ◽  
Storage Racks ◽  
Descriptive Method

ABSTRAK Rekam medis disimpan dalam rak penyimpanan agar terjaga kerahasiaanya, terhindar dari kerusakan dan mempermudah petugas dalam pengambilan dan pengembalian rekam medis. Agar pelayanan menjadi efektif dan efesien, selain memerlukan rak penyimpanan yang cukup, juga perlu ruangan penyimpanan yang bisa memuat rak penyimpanan tersebut agar dapat menyimpan berkas rekam medis pasien dalam jangka waktu tertentu guna pemeriksaan diwaktu yang akan datang dan memudahkan pengambilan kembali oleh petugas. Maka dari itu peneliti bertujuan untuk menegetahui luas ruangan berdasarkan kebutuhan rak saat ini di Rumah Sakit Umum Madani Medan tahun 2019. Penelitian ini menggunakan  metode deskriptif kuantitatif yaitu dengan memaparkan hasil penelitian apa adanya dan membandingkan dengan teori kemudian diambil kesimpulan. Subjek dalam penelitian ini adalah ruang penyimpanan berkas rekam medis rawat jalan, dan objek dalam penelitian ini adalah berkas rekam medis dan rak penyimpanan rawat jalan. Hasil penelitian ini menunjukkan bahwa jumlah rak penyimpanan berkas rekam medis rawat jalan di RSU Madani medan adalah 8 rak dengan luas ruangan 18,99 m2. Jika saat ini rumah sakit memiliki 8 rak, maka rumah sakit perlu menyediakan 10 rak lagi sehingga luas ruangan menjadi 48,82 m2 agar luas ruangan dapat tercukupi dan dapat memuat rak sesuai kebutuhan rumah sakit  sehingga tidak menyulitkan petugas penyimpanan dalam pengambilan maupun pengembalian rekam medis pasien.   Kata Kunci    :  Rekam Medis, Rak Penyimpanan, Luas Ruangan   ABSTRACT Medical records are stored in a storage rack to maintain confidentiality, avoid damage and make it easier for officers to retrieve and return medical records. In order for the service to be effective and efficient, in addition to requiring adequate storage shelves, storage rooms that can also contain storage shelves are needed so that they can store patient medical record files for a certain period of time for future examinations and facilitate retrieval by officers. Therefore the researcher aims to determine the area of ​​the room based on the needs of the current shelves at the Medan Madani General Hospital in 2019. This research uses a quantitative descriptive method by describing the results of the research as it is and comparing with the theory then conclusions are drawn. The subjects in this study were the outpatient medical record file storage room, and the object in this study was the medical record file and outpatient storage rack. The results of this study indicate that the number of outpatient medical record file storage racks in Medan Madani General Hospital is 8 shelves with an area of ​​18.99 m2. If the hospital currently has 8 shelves, the hospital needs to provide 10 more shelves so the room area becomes 48.82 m2 so that the room area can be fulfilled and can load the shelves according to the hospital's needs so that it does not make it difficult for the storage staff to retrieve or return the patient's medical record .

scholarly journals SOSIALISASI PELAKSANAAN SISTEM PENYIMPANAN BERKAS REKAM MEDIS DI KLINIK AS SALAM KOTA PADANG

2019 ◽  
Vol 3 (2(Jul-Des)) ◽  
pp. 130
Author(s):  
Sayati Mandia
Keyword(s):  
Health Service ◽  
Community Engagement ◽  
Medical Record ◽  
Medical Records ◽  
Health Workers ◽  
Storage System ◽  
Physical Damage ◽  
Filling System ◽  
Medical Person ◽  
Speed Up

Klinik merupakan pelayanan kesehatan yang menyelenggarakan dan menyediakan pelayanan medis dasar  atau spesialistik, dan diselenggarakan oleh satu atau lebih tenaga kesehatan  dan dipimpin oleh seorang tenaga medis. Setiap klinik wajib menyelenggarakan rekam medis. Salah satu penyelenggaran rekam medis adalah sistem penyimpanan berkas rekam medis. Sistem penyimpanan ini sangat penting untuk dilakukan karena dapat mempermudah berkas rekam medis yang akan disimpan dalam rak penyimpanan, mempercepat ditemukan kembali atau pengambilan berkas rekam medis yang disimpan dalam rak penyimpanan, mudah pengembaliannya, dan melindungi berkas rekam medis dari bahaya pencurian, bahaya kerusakan fisik, kimiawi, dan biologi. Pengabdian kepada masyarakat ini dilakukan dengan cara memberi sosialisasi kepada petugas rekam medis mengenai penyimpanan berkas rekam medis. Pengabdian ini membahas mengenai sistem penyimpanan yang dilaksanakan di klinik As salam kota padang. Hasil pengabdian ini berupa penambahan wawasan mengenai sistem penyimpanan rekam medis pasien. Kata kunci: Sistem Penyimpanan, Rekam medis, Klinik ABSTRACT Clinic is a health service that organizes and provides basic or specialist medical services, and is organized by one or more health workers and is led by a medical person. Each clinic is required to hold a medical record. One of the organization of medical records is a medical record filling system. Filling is very important because it can facilitate the medical record file to be stored in a storage rack, speed up rediscovering or retrieving medical record files stored in a storage rack, easy return, and protect medical record files from the danger of theft, physical damage, chemistry and biology. The community engagement is done by giving socialization to medical records officer regarding the filling of medical record files. This engagement discusses that filling system implemented in Clinis As salam. The results is increasing knowledge about medical record filling system.Keywords: Storage system, Medical record, Clinic

scholarly journals Overview Of The Medical Record Room in Sumber Public Health Center

2020 ◽  
Vol 7 (2) ◽  
pp. 49-54
Author(s):  
Nur Liya ◽  
Loura Weryco Latupeirissa ◽  
Eka Martaviantika Gusana
Keyword(s):  
Public Health ◽  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
Storage Space ◽  
Public Health Center ◽  
File Storage ◽  
Room Size ◽  
The Moment ◽  
Storage Racks

The distance between the aisle shelves in the medical record file storage space must meet the requirements for easy retrieval and maintenance. The total area of the room is adjusted to the needs assessment. The purpose of this study was to determine the distance between the storage shelves in Sumber Public Health Center, to know the needs of shelves for medical records file Sumber Public Health Center and to know the description of the medical record room in Sumber Public Health Center. This type of research is a descriptive method. The object of this research was the area of medical record room in Sumber Public Health Center, but to determine the average thickness of BRM in supporting the calculation of room size requirements the size of the sample used was 396 BRM. Sampling in this research is using random sampling with group sampling. The instruments used in this study used measuring aids (meters and micrometers), calculating aids, the formula for storing medical records and observation guidelines The results of this study are the distance between the passageways of the storage shelves at Sumber Public Health Center at the moment, which is 48 cm, the storage rack needs to store 46,353 medical records files as many as 9 shelves and the current medical record space at the Sumber Public Health Center is 5.74 m2. Based on the results of the measurement of the need for a room of medical records is 9.60 m2 so it requires the addition of 3.86 m2 of space. Thus the need for space is not sufficient because the needs of the current storage rack still requires the addition of storage racks so that it is also needed to increase the storage space. Puskesmas are expected to add more storage space for medical records or can switch to electronic medical records.

scholarly journals RANCANGAN KEBUTUHAN RAK DAN LUAS RUANGAN PENYIMPANAN REKAM MEDIS DI RUMAH SAKIT PUTRI HIJAU

2020 ◽  
Vol 5 (1) ◽  
pp. 53-61
Author(s):  
Welly Satria Dewi ◽  
Siti Muthmainnah
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Quantitative Method ◽  
Storage Space ◽  
Physical Damage ◽  
Patient Medical Record ◽  
File Storage ◽  
Storage Room ◽  
And Storage

  ABSTRAK Rekam medis disimpan dalam ruang penyimpanan agar memudahkan dalam pengambilan dan pengembalian berkas rekam medis. Kunjungan pasien yang meningkat mengakibatkan penambahan ketebalan dan penambahan rekam medis baru, sehingga rak menjadi penuh mengakibatkan proses penyimpanan dan pengembalian  kembali menjadi terhambat dan mengakibatkan kerusakan fisik pada berkas rekam medis. Maka peneliti bertujuan untuk mengetahui kebutuhan rak dan luas ruangan penyimpanan rekam medis di Rumah Sakit Putri Hijau. Penelitian ini menggunakan metode deskriptif kuantitatif yaitu dengan memaparkan hasil penelitian apa adanya dan membandingkan dengan teori kemudian diambil kesimpulan. Subjek dalam penelitian ini adalah ruang penyimpanan berkas rekam medis, objek dalam penelitian ini adalah berkas rekam medis dan rak penyimpanan. Hasil penelitian ini menunjukkan bahwa jumlah rak penyimpanan berkas  rekam medis di Rumah Sakit Putri Hijau adalah 20 rak dengan luas ruangan 100 m2. Terdapat 15 rak dengan luas ruangan 75 m2 diruang aktif dan 5 rak dengan luas ruangan 25m2 diruang inkatif. Dengan luas ruangan aktif yang telah tersedia mampu menampung penambahan kebutuhan rak rekam medis  aktif sebanyak  2 unit,  sehingga dengan tercukupinya rak  penyimpanan rekam medis dapat memudahkan petugas dalam menyimpan dan mengembalikan berkas rekam medis pasien serta terjaga kerahasiaan dan terhindar dari kerusakan fisik dokumen rekam medis.   Kata Kunci : Rekam Medis, Rak Penyimpanan, Luas Ruangan.   ABSTRACT Medical records are stored in a storage room to make it easier to retrieve and return medical record files. Increased patient visits result in increased thickness and addition of new medical records, so that the shelves become full resulting in the process of storage and return to be hampered and cause physical damage to the medical record file. Then the researchers aimed to determine the need for shelves and spacious medical record storage room at Putri Hijau Hospital. This research uses descriptive quantitative method that is by describing the results of the research as it is and comparing with the theory then conclusions are drawn. The subjects in this study were the medical record file storage space, the object in this study was the medical record file and storage rack. The results of this study indicate that the number of medical record file storage shelves at the Putri Hijau Hospital is 20 rack with room area of ​​100 m2. There are 15 shelves with a room area of ​​75 m2 in an active room and 5 shelves with a room area of ​​25 m2 in an inclusive room. With an active room area that is available to accommodate the need for additional active medical record shelves as much as 2 units, so that adequate storage of medical record shelves can facilitate officers in storing and returning patient medical record files and maintaining confidentiality and avoiding physical damage to medical record documents.

scholarly journals THE USE OF OUTGUIDE IN UNIT MEDICAL RECORD OUTPATIENT ARJAWINANGUN DISTRICTHOSPITALS CIREBON

2020 ◽  
Vol 7 (2) ◽  
pp. 43-45
Author(s):  
Chynditian ◽  
Riantina Luxiarti ◽  
Bayu Ajie Pradiptya
Keyword(s):  
Medical Record ◽  
District Hospital ◽  
Storage System ◽  
Storage And Retrieval ◽  
File Storage ◽  
Speed Up ◽  
The Subject ◽  
Quality Of Health Services ◽  
Descriptive Method

Provision of medical records files quickly and precisely will greatly help the quality of health services provided to patients. If the medical record file storage system that is used is not good, problems will occur that can interfere with the availability of medical record files. Therefore the existence of an outguide in the medical record file storage can help speed up the provision of medical record files and minimize errors in the storage of medical record files. The purpose of this study was to determine the use of outguides in the outpatient medical record unit at Arjawinangun District Hospital Cirebon. This type of research is a descriptive method The subject of this study was the outpatient medical record file storage officer at Arjawinangun District Hospital Cirebon with a total of 4 special officers in the storage and retrieval of medical record files. The instrument used in this study used checklist sheets. The results showed that 100% the use of outguide was not used in the process of searching medical record files because outguide availability was very limited. So when outguide not used properly, it can be errors in the storage of patient's medical record files.For this reason, the medical record unit must use the outguide properly in order to minimize the occurrence of misplacement of the patient's medical record file and speed up the time for the provision of the medical record file.

scholarly journals FAKTOR-FAKTOR YANG MEMPENGARUHI KETERLAMBATAN PENGEMBALIAN BERKAS REKAM MEDIS RAWAT JALAN DI UPT RUMAH SAKIT KHUSUS PARU TAHUN 2019

2020 ◽  
Vol 5 (1) ◽  
pp. 108-113
Author(s):  
Ali Sabela Hasibuan
Keyword(s):  
Service Delivery ◽  
Medical Record ◽  
Medical Records ◽  
Sampling Technique ◽  
Medical Record Data ◽  
Patient Medical Record ◽  
Descriptive Research ◽  
Record Data ◽  
Quantitative Descriptive ◽  
Time Required

ABSTRAK   Unit rekam medis merupakan bagian yang penting dalam suatu rumah sakit, karena rekam medis memuat kegiatan mulai dari penerimaan pasien, pencatatan, pengelolaan data rekam medis pasien, penyimpanan dan pengembalian berkas rekam medis.Selain itu, unit rekam medis harus mampu melayani permintaan informasi yang berkaitan dengan data rekam medis dengan cepat, tepat dan akurat pada waktu yang dibutuhkan.Salah satu faktor yang berpengaruh dalam kecepatan pemberian pelayanan kepada pasien adalah ketepatan waktu pengembalian berkas rekam medis ke unit rekam medis.Tujuan umum dari peneliti ini adalah untuk mengetahui faktor keterlambatan pengembalian berkas rekam medis rawat inap di UPT Rumah Sakit Khusus Paru Medan.Jenis penelitian ini menggunakan metode penelitian deskriptif kuantitatif.Populasi dalam penelitian petugas yang berkaitan dengan pengisian rekam medis diRS Khusus Paru yang berjumlah 15 orang, dengan teknik pengambilan sampel adalah total sampling yaitu berjumlah 15 orang.Berdasarkan hasil penelitian yang telah dilakukan  peneliti bahwa faktor yang paling mempengaruhi keterlambatan adalah menjalankan prosedur yang telah ditetapkan dan ketidaklengkapan  dalam pengisian dokumen rekam medis baik dalam identitas pasien dan ketepatan dalam pengisian diagnosis juga mempengaruhi keterlambatan dalam pengembalian berkas rekam medis dan menjalankan prosedur yang telah ditetapkan di rumah sakit pengembalian berkas rekam medis paling lama 1x24 jam, apabila pengembalian berkas rekam medis mengalami keterlambatan maka akan sangat berpengaruh terhadap assembling,analisis,coding,indixing,filling dan laporan. Kata Kunci                 : Pengembalian Rekam Medis. ABSTRACT   Medical record unit is an important part in a hospital, because medical records contain activities ranging from receiving patients, recording, managing patient medical record data, storing and returning medical record files. In addition, medical record units must be able to service requests for information relating with medical record data quickly, precisely and accurately at the time required. One of the factors that influence the speed of service delivery to patients is the timeliness of returning medical record files to the medical record unit. inpatient medical record at UPT Medan Special Lung Hospital. This type of research uses quantitative descriptive research methods. Population in the study of officers relating to filling medical records in the Special Lung RSR totaling 15 people, with the sampling technique is the total sampling which amounted to 15 people . Brilliant The results of research that have been conducted by researchers that the factors that most influence the delay are carrying out established procedures and incompleteness in filling medical record documents both in the patient's identity and accuracy in filling out the diagnosis also affect the delay in returning the medical record file and carry out the procedures specified in the hospital returns the medical record file for a maximum of 1x24 hours, if the return of the medical record file is delayed it will greatly affect the assembling, analysis, coding, indixing, filling and reporting.   Keywords: Returning Medical Records.

Analisis Unsur Manajemen dalam Pengolahan Rekam Medis di Rumah Sakit TNI AU Lanud Roesmin Nurjadin

2018 ◽  
Vol 1 (1) ◽  
pp. 20-25
Author(s):  
Henny Maria Ulfa
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Processing Method ◽  
Qualitative Approach ◽  
Check List ◽  
Training Material ◽  
Patient Medical Record ◽  
Qualitative Descriptive ◽  
Material Element ◽  
Descriptive Method

Hospitals must conduct a medical record activities according to Permenkes NO.269 / MENKES / PER / III / 2008 about Medical Record, to achieve the purpose of medical record processing required 5 management elements are: man, money, material, machine, and method. The medical record processing that has been implemented at the Hospital TNI AU LANUD Roesmin Nurjadin that is coding, coding only done for BPJS patients whose conducted by the officer with education background of D3 nursing, it be impacted to the storage part is wrong save and cannot found patient medical record file because are not returned. The purpose of this research is to know the element of management in the processing of medical records at the Hospital TNI AU LANUD Roesmin Nurjadin. This research is done by Qualitative descriptive method, Qualitative approach, instrument of data collection of interview guidance, observation guidance, check list register, and stationery, number of informant 6 people with inductive way data analysis. The result of this research found that Mans elements only amounts to 2 people so that officers work concurrently and have never attended training, material element and machines elements of medical record processing not yet use SIMRS and tracer, while processing method elements follow existing habits and follow the policy of hospital that is POP organization. Keywords: Management elements, medical record processing

scholarly journals Aspek Hukum Rekam Medis atau Rekam Medis Elektronik sebagai Alat Bukti Dalam Transaksi Teurapetik

2017 ◽  
Vol 3 (2) ◽  
pp. 359-383 ◽  
Author(s):  
Sudjana Sudjana
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Medical Records ◽  
Health Workers ◽  
Legal Aspects ◽  
Literature Study ◽  
Descriptive Research ◽  
Positive Law ◽  
Approach Method ◽  
Administrative Sanctions

This study aims to obtain information on: first, the obligation to create and conceal Electronic Medical Record and its juridical consequences; Secondly, due to the law of absence or error in the manufacture of Electronic Medical Records and the position of Electronic Medical Record as a tool in the theoretical transactions.The research method used is normative juridical approach method, analytical descriptive research specification, research phase is done through literature study to examine primary law material, secondary law material, and tertiary law material. Data collection techniques are conducted through document studies, conducted by reviewing documents on positive law. Furthermore, the method of data analysis is done through normative qualitative.The results of the study indicate: Legal aspects of Medical Record or Electronic Medical Record   in Teurapetik Transactions related to: first, the obligation of health workers in coaching and health services to make Medical Record or Electronic Medical Record correctly and responsible for secrecy because it is the opening of Medical Record or Electronic Medical Record without With the permission of the patient having the consequences of criminal law. The absence or misuse of the Medical Record or Electronic Medical Record means that health workers may be subject to criminal, civil and administrative sanctions. Second, the position of  Medical Record or Electronic Medical Record is evidence in the form of a letter (if given outside the court), and expert information (if delivered in court).

scholarly journals Medical Record Storage System Analysis On The Effectiveness Of Patient Services

2021 ◽  
Vol 1 (1) ◽  
pp. 28-38
Author(s):  
Yoki Muchsam ◽  
Ilham Rizkiana Muharam
Keyword(s):  
Public Health ◽  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
System Analysis ◽  
Storage System ◽  
Health Care Facilities ◽  
Public Health Center ◽  
Additional Tool ◽  
Alignment System

This study aims to determine and analyze the medical record storage system on the effectiveness of patient care at the Cikole Public Health Center. The research method used is quantitative with inferential statistical analysis techniques. Data collection techniques by means of observation, interviews and questionnaires. Cikole Lembang Public Health Center is one of the first level health care facilities. Based on observations, the storage system used is a regional storage system in which each region starts from the first digit. There are 2 officers who work in the medical records section of the Cikole Public Health Center. With the storage system used, there are several shortcomings, namely the occurrence of misfiles and duplication. To find out whether there is an analysis of the medical record storage system on the effectiveness of the service, the author gives a questionnaire to the Cikole Public Health Center officers. The results of the questionnaire also show that the highest percentage level is found in item no.7, namely the decentralized storage system is in accordance with the target of 71%. Then the second is item no. 8, namely a decentralized storage system that allows the provision of medical record files on time by 61%. From the results of interviews with medical records officers, suggestions and input were given: (1). The storage system used was changed to centralization so that the alignment system was not duplicated; (2). The use of bindex as an additional tool to make storage neater and easier.

scholarly journals Completeness of informed consent in supporting national standard accreditation of patient and family rights 5 hospitals at Ropanasuri surgical special hospital in Padang

2019 ◽  
Vol 6 (11) ◽  
pp. 4639
Author(s):  
Yastori .
Keyword(s):  
Informed Consent ◽  
Medical Record ◽  
Medical Records ◽  
National Standards ◽  
National Standard ◽  
National Hospital ◽  
Microsoft Excel ◽  
Patient Medical Record ◽  
Special Hospital ◽  
Descriptive Method

Background: Completeness of informed consent is one indicator in supporting the accreditation of national hospital standards through the assessment of patient and family rights (PFR) assessment standards 5. In the health service process, informed consent can also be used as evidence and has a strong legal value in the form of a sheet of paper containing the doctor’s explanation about the diagnosis of the disease and the actions that will be performed on the patient.Methods: This research uses descriptive method with a qualitative approach. The population used was the entire patient medical record file in 2018, which was 3.093 medical record files. Sampling was done by random sampling using a formula according to Notoatmodjo for the calculation of the number of samples and obtained 355 files of medical records. Data processing using Microsoft Excel computer programs. For observing the completeness of the standard rights of patients and families using national standards for hospital accreditation.Results: Based on the analysis of 355 medical record files at Ropanasuri specialty hospital it is known that 296 pieces of informed consent were filled in with a percentage of 83.38%, 59 sheets of informed consent were incomplete with a percentage of 16.62%. The results showed the greatest incompleteness found in filling the informed consent items of witness signatures of 2.81%, providing information on the completeness of filling the doctor's identity by 2.54% and the name of the witness 1.70% on filling the authentication.Conclusions: 296 pieces of informed consent were filled in with a percentage of 83.38%, 59 sheets of informed consent were incomplete with a percentage of 16.62%.

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