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  

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 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 A Psychiatric Version of the New Aberdeen Medical Record

1983 ◽  
Vol 7 (11) ◽  
pp. 201-202
Author(s):  
Keith J. B. Rix ◽  
Betty McNally ◽  
Margaret Johnson
Keyword(s):  
Drug Treatment ◽  
Medical Record ◽  
Medical Records ◽  
Psychiatric Patients ◽  
Hospital Medical ◽  
Psychiatric Units

When Wilson et al (1978) described ‘The new Aberdeen Medical Record,’ they stated: ‘The bulk and disarray of many hospital medical records make it impossible to review and retrieve information easily, hamper the proper care of patients and cause much time to be wasted … when papers accumulate chaotically in the folders much time is wasted in clumsy attempts to retrieve information; important facts about patients and their problems and drug treatment are obscured.’ The same problems apply to the records of psychiatric patients, and this paper describes the adaptation of the Aberdeen Medical Record for use in psychiatric units and hospitals.

scholarly journals Literature Review: Analisis Faktor Penyebab Keterlambatan Pengembalian Rekam Medis di Rumah Sakit

2021 ◽  
Vol 9 (1) ◽  
pp. 21-29
Author(s):  
Alfita Dewi ◽  
Ilma Nuria Sulrieni ◽  
Chamy Rahmatiqa ◽  
Fajrilhuda Yuniko
Keyword(s):  
Literature Review ◽  
Medical Record ◽  
Medical Records ◽  
Research Literature ◽  
Record System ◽  
Medical Record System ◽  
Causes Of Delays ◽  
Process Component ◽  
Method Factors

AbstractThe quality of medical records describes the quality of health services provided. The return of the medical record file starts from the file being in the treatment room until the file is returned to the medical record unit. Incomplete and not immediately filled out medical resumes cause delays in returning medical records. Therefore, the return of the medical record system is quite important in the medical record unit. This study is a literature review, to see the causes of delays in returning medical records at hospitals in Indonesia. Sources of data come from published research literature, with a total of 18 research articles. Data collection was carried out from March to June 2020. The factor causing the delay in returning medical records was the highest due to the input component. From all journals, 100% of the delays in returning medical records were caused by the input component (Man, Money, Materials, Method, Machine) and 33.3% by the process component. Of the input components, 83.3% were caused by Man factors, 77.8% Method factors, 33.3% Materials factors, 27.8% Machine factors, and 5.5% Money factors. Each hospital must have a clear and firm policy in overcoming delays in returning medical records, with clear and firm policies, the causative factors such as Man, Money, Material, Method, Machine can be minimized and the accuracy of returning medical records can be maximized.Keywords: return, incompleteness, medical records, literature, reviewAbstrakMutu rekam medis menggambarkan mutu pelayanan kesehatan yang diselenggarakan. Pengembalian Rekam Medis dimulai dari berkas tersebut berada diruang rawat sampai berkas tersebut kembali ke unit rekam medis. Pengisian resume medis yang tidak lengkap dan tidak segara dilakukan menyebabkan keterlambatan pengembalian rekam medis. Maka dari itu, pengembalian rekam medis sistem yang cukup penting di unit rekam medis. Penelitian ini merupakan literature review, untuk melihat penyebab keterlambatan pengembalian rekam medis di Rumah Sakit di Indonesia. Sumber data berasal dari literatur hasil penelitian yang telah dipublikasikan, dengan jumlah artikel penelitian sebanyak 18 artikel. Pengambilan data dilakukan dari bulan Maret-Juni 2020. Faktor penyebab keterlambatan pengembalian rekam medis tertinggi disebabkan oleh komponen input.  Dari semua jurnal sebanyak 100% keterlambatan pengembalian rekam medis disebabkan oleh komponen input (Man, Money, Materials, Methode, Machine) dan sebanyak 33,3% oleh komponen proses. Dari komponen input tersebut, sebanyak 83,3 % disebabkan oleh faktor Man, 77,8% faktor Methode, 33,3% faktor Materials, 27,8% faktor Machine, dan 5,5% faktor Money. Setiap rumah sakit harus memiki kebijakan yang jelas dan tegas dalam mengatasi keterlambatan Pengembalian Rekam Medis, dengan kebijakan yang jelas dan tegas, faktor penyebab seperti Man, Money, Material, Method, Machine dapat di minimalisir dan ketepatan Pengembalian Rekam Medis dapat dilakukan secara maksimal.Keywords: keterlambatan, pengembalian, rekam medis, literature review 

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

Perencanaan Arsitektur Sistem Informasi Rekam Medis dan Monitoring Gizi Buruk Berbasis Cloud Computing (Studi Kasus: Dinas Kesehatan Propinsi Jawa Barat)

2017 ◽  
Vol 8 (3) ◽  
Author(s):  
Ova Nurisma Putra
Keyword(s):  
Cloud Computing ◽  
Information System ◽  
Medical Record ◽  
Medical Records ◽  
Monitoring And Evaluation ◽  
Open Group ◽  
Development Method ◽  
Information System Architecture ◽  
Architecture Framework ◽  
Architecture Development

Abstract. West Java Provincial Health Office still faces difficulties in managing information, especially in medical records. Recording and reporting of malnutrition are still done in some stages starting from collecting data from village midwives, puskesmas, Regency/City Health Office then Provincial Health Office and forwarded to the the central office. It is necessary to manage information through service system by utilizing Cloud Computing based on information technology. This research uses The Open Group Architecture Framework (TOGAF) approach in Architecture Development Method (ADM), from Architecture Capability Iteration to  Architecture Development Iteration. Monitoring and Evaluation (M & E) are two integrated activities in the context of controlling a program. The results of this research are planning a medical record information system architecture and monitoring malnutrition based on Cloud Computing with the name of M2Rec (Medical Record and Monitoring) in the form of integrated recommendation and development between current information system and proposed information system architecture.Keywords: togaf adm, medical record and monitoring, cloud computing Abstrak. Perencanaan Arsitektur Sistem Informasi Rekam Medis dan Monitoring Gizi Buruk Berbasis Cloud Computing. Dinas Kesehatan Propinsi Jawa Barat masih mengalami kesulitan dalam pengelolaan informasi yang baik, terutama pada proses rekam medis, pencatatan dan pelaporan gizi buruk masih dilakukan secara bertingkat mulai pengumpulan data dari bidan desa, puskesmas, Dinas Kesehatan Kabupaten/Kota kemudian Dinas Kesehatan Propinsi dan diteruskan ke pusat. Sehingga perlu diupayakan pengelolaan informasi melalui sistem pelayanan dengan memanfaatkan teknologi informasi berbasis Cloud Computing. Penelitian ini menggunakan pendekatan framework The Open Group Architecture Framework (TOGAF) Architecture Development Method (ADM), yaitu iterasi ke satu pada Architecture Capability Iteration daniterasi ke dua pada Architecture Development Iteration. Monitoring dan Evaluasi (M&E) merupakan dua kegiatan terpadu dalam rangka pengendalian suatu program. Hasil dari penelitian ini adalah perencanaan arsitektur sistem informasi rekam medis dan monitoring gizi buruk berbasis Cloud Computing dengan nama M2Rec (Medical Record and Monitoring) yang berupa rekomendasi integrasi dan pengembangan antara sistem informasi berjalan saat ini dengan arsitektur sistem informasi yang diusulkan.Kata kunci: togaf adm, medical record and monitoring, cloud computing.

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 Automatic Placement of Genomic Research Results in Medical Records: Do Researchers Have a Duty? Should Participants Have a Choice?

2015 ◽  
Vol 43 (4) ◽  
pp. 827-842
Author(s):  
Anya E.R. Prince ◽  
John M. Conley ◽  
Arlene M. Davis ◽  
Gabriel Lázaro-Muñoz ◽  
R. Jean Cadigan
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Genomic Research ◽  
Research Results ◽  
Research Participants ◽  
Difficult Question ◽  
Automatic Placement ◽  
Study Participants ◽  
Research Studies

The growing practice of returning individual results to research participants has revealed a variety of interpretations of the multiple and sometimes conflicting duties that researchers may owe to participants. One particularly difficult question is the nature and extent of a researcher’s duty to facilitate a participant’s follow-up clinical care by placing research results in the participant’s medical record. The question is especially difficult in the context of genomic research. Some recent genomic research studies — enrolling patients as participants — boldly address the question with protocols dictating that researchers place research results directly into study participants’ existing medical records, without participant consent. Such privileging of researcher judgment over participant choice may be motivated by a desire to discharge a duty that researchers perceive themselves as owing to participants. However, the underlying ethical, professional, legal, and regulatory duties that would compel or justify this action have not been fully explored.

ANALISIS PELAKSANAAN REKAM MEDIS DI RUMAH SAKIT IBU DAN ANAK (RSIA ) WIDIYANTI

2018 ◽  
Vol 11 (1) ◽  
Author(s):  
Fera Siska
Keyword(s):  
Qualitative Research ◽  
Data Analysis ◽  
Data Collection ◽  
Human Resources ◽  
Medical Record ◽  
Medical Records ◽  
Depth Information ◽  
Operational Procedure ◽  
Patient Registration ◽  
Qualitative Research Design

ABSTRACTBackground : Medical record is one of the most important pillars that can not be considered trivial in a hospital, with the development of medical scienceCommon Purpose : To find in-depth information about the implementation of medical records at the hospital Widiyanti PalembangResearch Method : Qualitative research design with data collection techniques are conducted in triangulation, The data analysis is inductive, and the results of the study are emphasized more at the meaning than the generalization. The Research Results : the Implementation of medical records have been running but there is no medical record organization, the implementation of medical record activities done by rolling. Human Resources (HR) medical records should be placed specifically in the medical record along with clear tasks. Method of organizing medical record has been run although the result is not optimal, because Standard Operational Procedure (SOP) that made not socialized. Facilities and infrastructure that support the implementation of the medical record is good, marked by the existence of a special records archive medical records. Facilities and infrastructure such as chairs, desks, computers, patient registration books and outpatient registration and inpatient services are available, do not have budget funds for medical record implementation, especially by sending medical recruiter for trainingConclusion : Implementation of medical records have been running but not optimal.

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