scholarly journals LITERATURE REVIEW : ASPEK KEAMANAN DAN KERAHASIAAN DOKUMEN REKAM MEDIS DI RUMAH SAKIT

2021 ◽  
Vol 1 (1) ◽  
pp. 36-42
Author(s):  
Nur Husnina ◽  
Trismianto Asmo Sutrisno
Keyword(s):  
Literature Review ◽  
Medical Record ◽  
Medical Records ◽  
Raw Materials ◽  
Google Scholar ◽  
Physical Aspect ◽  
Vacuum Cleaner ◽  
File Storage ◽  
Storage Room ◽  
Access Rights

Abstract Security and confidentiality are very important factors in managing medical record files. In terms of security, the medical record file storage room was found to be dusty and humid which caused moldy medical records and also the raw materials for medical record folders still use low-quality materials. In the aspect of confidentiality, there is still a distribution of medical record files that have not been kept confidential and there are still damaged, folded and forms that are separated from the medical record folder, and left alone without any treatment on the damaged medical record. This study aims to determine the security and confidentiality of medical records. This study uses a literature review method with a search strategy using Google Scholar with the keywords Security Aspects of Confidentiality and Medical Records. The results of this study are the safety aspect in terms of the physical aspect of the ink used in black is uniform, the paper used is A4 size and weighs 70 grams. Biological aspects of the presence of fungi, bookworms, and insects such as termites, cockroaches, and mice. The chemical aspect of the medical record officer eating or drinking in the medical record room. Aspects of confidentiality there are still medical record officers who enter the medical record filing and medical record documents are still found that were brought by the patient or lost. Suggestions for the security aspect of the medical record file, the storage room should be equipped with maintenance tools such as a vacuum cleaner, spraying insects or given camphor, medical record storage space is limited by access rights such as fingerprints. Aspects of confidentiality of patients who consult to other polyclinics or want to carry out further examinations at supporting facilities are delivered by medical record distribution officers. Keywords              : Confidentiality Security Aspect, Medical Records   Abstrak Keamanan dan kerahasiaan adalah faktor yang sangat penting dalam pengelolaan berkas rekam medis. Dalam aspek keamanan terdapat pada ruang penyimpanan berkas rekam medis ditemukan ruangan berdebu dan lembab yang menyebabkan rekam medis berjamur dan juga pada bahan baku map rekam medis masih menggunakan bahan yang berkualitas rendah. Dalam aspek kerahasiaan masih terdapat pendistribusian berkas rekam medis yang belum terjaga kerahasiaan dan masih terdapat rekam medis yang rusak, terlipat dan terdapat formulir yang lepas dari map rekam medis, dan dibiarkan begitu saja tanpa ada perawatan pada rekam medis yang rusak. Penelitian ini bertujuan untuk mengetahui keamanan dan kerahasiaan rekam medis. Penelitian ini menggunakan metode literature review dengan strategi pencarian menggunakan Google Scholar dengan kata kunci Aspek Keamanan Kerahasiaan dan Rekam Medis. Hasil penelitian ini adalah aspek keamanan ditinjau dari aspek fisik tinta yang digunakan warna hitam sudah seragam, kertas yang digunakan ukuran A4 berat 70 gram. Aspek biologi adanya jamur, kutu buku, dan serangga seperti rayap, kecoa, dan tikus. Aspek kimiawi adanya petugas rekam medis makan atau minum di ruang rekam medis. Aspek kerahasiaanya masih ada petugas rekam medis yang masuk ke filing rekam medis dan masih ditemukan dokumen rekam medis yang di bawa pasien atau hilang. Saran aspek keamanan berkas rekam medis ruang penyimpanan hendaknya dilengkapi alat pemeliharaan seperti vacuum cleaner, dilakukan penyemprotan serangga atau diberi kamfer, ruang penyimpanan rekam medis di batasi oleh hak akses seperti  fingerprint. Aspek kerahasiaan pasien yang konsultasi ke poliklinik lain atau ingin melakukan pemeriksaan lanjutan di fasilitas penunjang diantarkan oleh petugas distribusi rekam medis. Kata Kunci          : Aspek Keamanan Kerahasiaan, Rekam Medis

scholarly journals Tinjauan Literatur: Faktor-Faktor Penyebab Kelengkapan Pengisian Rekam Medis Rawat Inap Rumah Sakit

2020 ◽  
Vol 3 (2) ◽  
pp. 46-52
Author(s):  
Putu Adiz Siwayana ◽  
Ika Setya Purwanti ◽  
Putu Ayu Sri Murcittowati
Keyword(s):  
Quality Of Service ◽  
Literature Review ◽  
Medical Record ◽  
Medical Records ◽  
Health Workers ◽  
Medical Personnel ◽  
Google Scholar ◽  
Incomplete Filling ◽  
Evaluation And Monitoring

Every health facility, whether it is primary, secondary, tertiary, is required to maintain medical records in order to achieve administrative order. Incomplete (incomplete) medical records will affect the service process provided by health workers and have an impact on the quality of service of a hospital. This study aims to determine the factors causing the incomplete filling of inpatient medical records. This study uses a literature review method. The strategy in searching literature reviews is using Google Scholar. In the search phase, articles are limited to publications from 2015-2020. The keywords used are the factors causing incomplete medical record filling. The search results obtained 10 articles and then 5 articles were taken. The results of the literature review show that the factors causing the incompleteness of filling in medical records as a whole can be seen from the lack of knowledge, motivation and awareness of medical personnel about medical records. The meeting as a means of communication between caregivers and management has not yet been implemented to discuss evaluation and monitoring as well as sanctions for officers who do not complete medical records. lack of socialization on filling out medical records. Unsystematic arrangement of medical record forms. Limited availability of funds or budget to support medical record service activities. Conclusion Hospitals need to pay attention to the factors causing the incompleteness of filling in medical records so that filling in medical records is complete according to standards. So that the quality of service, especially the quality of patient medical records.AbstrakSetiap fasilitas kesehatan baik tingkat primer, sekunder, tersier wajib menyelenggarakan rekam medis agar tercapainya tertib administrasi. Ketidaklengkapan (Incomplete) rekam medis akan berpengaruh terhadap proses pelayanan yang diberikan oleh petugas kesehatan dan berdampak pada kualitas pelayanan suatu rumah sakit. Penelitian ini bertujuan untuk mengetahui faktor penyebab ketidaklengkapan pengisian rekam medis rawat inap. Penelitian ini menggunakan metode literatur review. Strategi dalam pencarian literatur review menggunakan Google Scholar. Pada tahap pencarian artikel dibatasi terbitan dari tahun 2015-2020. Kata kunci yang digunakan adalah Faktor Penyebab ketidaklengkapan pengisian rekam medis. Hasil penelusuran artikel didapatkan 10 artikel dan selanjutnya diambil 5 artikel. Hasil dari literatur review didapatkan faktor penyebab ketidaklengkapan pengisian rekam medis secara keseluruhan, penyebabnya dapat dilihat dari kurangnya pengetahuan, motivasi dan kesadaran dari petugas rekam medis tentang rekam medis. Belum terlaksananya rapat sebagai wadah komunikasi antara pemberi asuhan dan manajemen yang membahas evaluasi dan monitoring serta sanksi bagi petugas yang tidak mengisi rekam medis dengan lengkap. kurangnya sosialisasi pengisian rekam medis. Susunan formulir rekam medis yang tidak sistematis. Terbatasnya ketersediaan dana atau anggaran untuk mendukung kegiatan pelayanan rekam medis. Kesimpulan Rumah sakit perlu memperhatikan  faktor penyebab ketidaklengkapan pengisian rekam medis sehingga pengisian rekam medis menjadi lengkap sesuai dengan standar. Sehingga  mutu dari pelayanan terutama mutu rekam medis pasien.

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 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 .

A Literature Review of Medical Record Keeping by Foreign Medical Teams in Sudden Onset Disasters

2015 ◽  
Vol 30 (2) ◽  
pp. 216-222 ◽  
Author(s):  
Anisa J. N. Jafar ◽  
Ian Norton ◽  
Fiona Lecky ◽  
Anthony D. Redmond
Keyword(s):  
Literature Review ◽  
Medical Record ◽  
Medical Records ◽  
Sudden Onset ◽  
World Health ◽  
Publication Type ◽  
Data Set ◽  
Record Keeping ◽  
Medical Teams

AbstractBackgroundMedical records are a tenet of good medical practice and provide one method of communicating individual follow-up arrangements, informing research data, and documenting medical intervention.MethodsThe objective of this review was to look at one source (the published literature) of medical records used by foreign medical teams (FMTs) in sudden onset disasters (SODs). The published literature was searched systematically for evidence of what medical records have been used by FMTs in SODs.FindingsThe style and content of medical records kept by FMTs in SODs varied widely according to the published literature. Similarly, there was great variability in practice as to what happens to the record and/or the data from the record following its use during a patient encounter. However, there was a paucity of published work comprehensively detailing the exact content of records used.InterpretationWithout standardization of the content of medical records kept by FMTs in SODs, it is difficult to ensure robust follow-up arrangements are documented. This may hinder communication between different FMTs and local medical teams (LMTs)/other FMTs who may then need to provide follow-up care for an individual. Furthermore, without a standard method of reporting data, there is an inaccurate picture of the work carried out. Therefore, there is not a solid evidence base for improving the quality of future response to SODs. Further research targeting FMTs and LMTs directly is essential to inform any development of an internationally agreed minimum data set (MDS), for both recording and reporting, in order that FMTs can reach the World Health Organization (WHO) standards for FMT practice.JafarAJN, NortonI, LeckyF, RedmondAD. A literature review of medical record keeping by foreign medical teams in sudden onset disasters. Prehosp Disaster Med. 2015;30(2):1-7.

scholarly journals Study Literature Review On Returning Medical Record Documents Using HOT-FIT Method

2021 ◽  
Vol 1 (1) ◽  
pp. 61-65
Author(s):  
Deni Maisa Putra ◽  
Oktamianiza Oktamianiza ◽  
Mega Yuniar ◽  
Washi Fadhila
Keyword(s):  
Literature Review ◽  
Medical Record ◽  
Medical Records ◽  
Descriptive Analysis ◽  
Net Benefit ◽  
Literature Study ◽  
Return Policy ◽  
Record Section ◽  
Doctors And Nurses

The return of medical record files is a system that is quite important in medical records, because the return of medical records starts from the file in the inpatient room until it returns to the medical record section in accordance with the return policy, which is 2x24 hours. The method used is a literature study with descriptive analysis which is done by describing the facts that exist then being analyzed, described, looking for similarities, views, and summaries of several studies. The results of the literature study show that humans are not responsible for returning medical record files, the organization lacks supervision from the management of returning files, technology (technology) with technology can assist in returning medical record files. So it is necessary to pay attention to the 3 components, so that it can produce a benefit (Net Benefit) from returning the medical record document. Based on the results of the study, it can be concluded that the factors that influence the return of medical record documents are in terms of the HOT-FIT method, (human) where the officers lack a sense of responsibility for medical record documents, and doctors and nurses do not pay attention to the form of filling out record documents medical records, so that it becomes an obstacle in returning medical record documents. It's good to have good supervision from the management.

scholarly journals SOSIALISASI PELAKSANAAN SISTEM PENGGUNAAN TRACER SEBAGAI PELACAK BERKAS REKAM MEDIS PADA RUMAH SAKIT NAILI DBS PADANG

2019 ◽  
Vol 3 (2) ◽  
pp. 172
Author(s):  
Yastori Yastori
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Fast Time ◽  
Length Of Service ◽  
File Storage ◽  
Quality Of Health Services ◽  
Health Services Needs ◽  
Frequent Problem ◽  
Record Section

Peningkatan mutu layanan kesehatan perlu dilakukan terutama bagi rumah sakit. Rekam medis yang hilang, salah letak, missfile sulit ditemukan dalam waktu yang cepat menjadi permasalahan yang sering terjadi dan mempengaruhi kualitas pelayanan dan menjadi pemicu permasalahan terjadinya berkas rekam medis ganda sehingga mempersulit pengembalian berkas rekam medis sesuai urutan dan mengakibatkan lamanya pelayanan terhadap pasien. Berdasarkan survei pendahuluan, rumah sakit Naili DBS belum menggunakan tracer untuk menandai berkas keluar. Metode yang digunakan adalah observasi dengan wawancara dan diskusi mengenai permasalahan dibagian rekam medis terutama bagian penyimpanan dan pelacakan berkas rekam medis. Pendidikan diberikan melalui sosialisasi pentingnya penggunaan tracer, sistem penggunaan dan tahapan dalam mempersiapkan tracer. Kegiatan ini bertujuan untuk menciptakan budaya  pemanfaatan tracer sebagai kartu pelacak berkas rekam medis keluar dari rak penyimpanan berkas, dilaksanakan pada 11 April 2019 dan berjalan lancar. Hasil yang diperoleh yaitu bahwa di rumah sakit Naili DBS belum menggunakan tracer dan cara pelacakan berkas rekam medis dengan melihat nomor rekam medis pada saat pasein melakukan pendaftaran sehingga membutuhkan waktu yang lebih lama jika dibandingkan dengana adanya tracer. Setelah diadakan sosialisasi ini, bagian rekam medis di rumah sakit Naili DBS memahami akan pentingnya tracer pada bagian rekam medis di rumah sakit.  Kata kunci : Tracer, Rekam Medis, Missfile ABSTRACT Improving the quality of health services needs to be done especially for hospitals. Missing medical records, misplaced, missfiles are difficult to find in a fast time that is a frequent problem that affects the quality of service and triggers problems with the occurrence of multiple medical record files, making it difficult to return the medical record files in order and result in length of service to patients. Based on preliminary surveys, the Naili DBS hospital has not used tracers to mark outgoing files. The method used is observation with interviews and discussions about problems in the medical records section, especially the storage and tracking of medical record files. Education is given through the socialization of the importance of using tracers, usage systems and stages in preparing tracers. This activity aims to create a culture of utilizing tracers as tracking cards for medical record files off the file storage shelves, held on April 11, 2019 and running smoothly. The results obtained are that the Naili DBS hospital has not used tracer and how to track medical record files by looking at the medical record number at the time of registration so that it takes longer than the tracer. After this socialization, the medical records section at Naili DBS Hospital understood the importance of tracers in the medical record section at the hospital. Keywords: Tracer, Medical Record, Missfile

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 KETIDAKLENGKAPAN REKAM MEDIS RAWAT INAP DI RUMAH SAKIT

2021 ◽  
Vol 1 (2) ◽  
Author(s):  
NEVITA RAHMAWATI NEVITA
Keyword(s):  
Literature Review ◽  
Medical Record ◽  
Medical Records ◽  
Inpatient Treatment ◽  
Hospital Records ◽  
Hospital Medical ◽  
Treatment Step

ABSTRAK Latar Belakang : Analisis ketidaklengkapan pengisian rekam medis sangat diperlukan, guna mengetahui seberapa besar angka ketidaklengkapan pengisian catatan medis (AKLPCM) di RSU Mitra Medika pada tahun 2018. Ditemukan bahwa dari seluruh berkas rekam medis pasien pulang dari rumah sakit terdapat 13.279 berkas terdapat ketidaklengkapan pengisian sebanyak 7,66% (1.017) berkas. Salah satu diantaranya adalah ketidaklengkapan pengisian resume medis, ketidaklengkapan pengisian identitas pasien sebanyak 5 formulir (16,6%), anamnese 4 (13,3%), pemeriksaan fisik 2 (6,6%), diagnosa 1 (6,6%), pemeriksaan penunjang 4 (13,3%) dan tindakan medis sebanyak 2 formulir (6,6%). Tujuan : Tujuan dari literature review ini adalah untuk untuk menganalisis Ketidaklengkapan Rekam Medis Rawat Inap Di Rumah Sakit. Metode : penelitian ini menggunakan desain literature review yaitu uraian tentang teori, bahan dan isi penelitian yang mengkaji tentang ketidaklengkapan rekam medis rawat inap di rumah sakit berdasarkan literature yang di review. Hasil : berdasarkan 8 jurnal di jelaskan bahwa Pengisian ketidaklengkapan rekam medis dari hasil penelitian menunjukan bahwa tidak lengkap masih tinggi pada angka 100% menandahkan kejadian ketidaklengkapan masih sering terjadi dan tidak sesuai dengan standart kelengkapan berkas rekam medis. Kesimpulan : Mengadakan monitoring evaluasi minimal 1 minggu sekali, membuat tim monitoring kelengkapan berkas  untuk memantau pelaksanaan rekam medis di rumah sakit Kesimpulan : Mengadakan monitoring evaluasi minimal 1 minggu sekali, membuat tim monitoring kelengkapan berkas  untuk memantau pelaksanaan rekam medis di rumah sakit   Kata Kunci : Ketidaklengkapan rekam medis, Rawat Inap, Langkah meningkatkan kelengkapan     ABSTRACT Background: incompleteness analysis of medical record-charging is essential, in order to see how high the incompleteness of medical records (aklpcm) in medika's partner-general general in 2018. It was found that from all the records of patients returning from the hospital there were 13,279 files of this incompleteness charging 7.66% (1,017) of the files. One is the incompleteness of medical resumes, the incompleteness of the patient's 5 forms (166%), anamnese 4 (13.3%), physical 2 (6.6%), diagnostic 1 (6.6%), 4 (13.3%) and 2 forms (6.6%) medical action. Purpose: the purpose of this literature review is to analyze the incompleteness of hospital hospital medical records. Method: the study USES the design literature review, which is a description of theory, the material and content of the study that deals with the incompleteness of medical hospital records based on the literature contained in the review. Results: according to 8 journals explain that the application of incompleteness of medical records from research shows that incomplete remains high at 100% indicating an occurrence of incompleteness is still frequent and incompatible with the standard for a medical record file. Conclusion: install a minimum evaluation monitoring once a week, creating a file monitoring team to monitor medical records at the hospital.   Keywords: of incompleteness medical records, inpatient treatment, step up completeness  

scholarly journals Rancang Bangun Sistem Informasi Retensi Rekam Medis dengan Metode Imaging Berbasis Web

2019 ◽  
Vol 2 (1) ◽  
pp. 33-39
Author(s):  
Ahmad Junaidi ◽  
Khairul Zaman
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Data Availability ◽  
Private Hospitals ◽  
Application System ◽  
Web Based ◽  
Structured System ◽  
Access Rights ◽  
Diverse Data ◽  
The City

Medical record is a file that contains notes and documents about the patient's identity, examination, treatment, actions and other services that have been given to the patient. Based on Minister of Health Regulation No.269 / Menkes / Per / III / 2008 the medical record file can be destroyed (retention) after being stored for a period of 5 (five) years from the last date the patient was treated or returned to avoid the buildup of non-active medical record documents. As one of the private hospitals in the city of Padang that has been operational for 14 years, Siti Rahmah Islamic Hospital has carried out the process of destroying medical record documents with imaging methods and storing them to an external hard drive before the medical record file is destroyed to anticipate various needs. relating to medical records, for example, a medical record that is still valuable to be needed can be searched and reprinted. However, the method used is not optimal because of the potential for data loss and the difficulty of the data search process and has not been managed using an information system in the form of a truly computerized program. Optimizing data processing is needed so that integrity, access rights and data availability can be maintained. The application system that will be proposed later uses PHP and Mariadb programming and web-based. The results of the image will be processed in an application and stored in the database. The diverse data will be managed well, easily and safely in a well-structured system. Keywords: Information Systems, Retention, Imaging, Medical Records, Web  

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.

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