ANALISIS SISTEM PENGELOLAAN BERKAS REKAM MEDIS DI RUMAH SAKIT UMUM DAERAH ENCIK MARIYAM KABUPATEN LINGGA

ANALYSIS OF MEDICAL RECORD MANAGEMENT SYSTEM IN ENCIK MARIYAM REGIONAL GENERAL HOSPITAL, LINGGA REGENCY

https://doi.org/10.25311/kesmas.Vol2.Iss1.508

Authors

  • RIZKA LISMAYULI Rizka pekanbaru
  • Leon Candra Universitas Hang Tuah Pekanbaru
  • Sherly Vermita Warlenda Universitas Hang Tuah Pekanbaru

Keywords:

SDM, SOP, Sarana prasarana, Fasilitas fisik penyimpanan

Abstract

Rekam Medis adalah berkas yang berisikan catatan dan dokumen
tentang identitas pasien, pemeriksaan, pengobatan, tindakan
medis lain pada sarana pelayanan kesehatan untuk rawat jalan,
rawat inap baik dikelola pemerintah maupun swasta.
Permasalahan yang ditemukan di RSUD Encik Mariyam
Kabupaten Lingga sudah melaksanakan kegiatan rekam medis,
namun dalam pengelolaan rekam medis belum berjalan optimal.
Penelitian ini bertujuan untuk menganalisis penyebab belum
terlaksananya pengelolaan rekam medis secara optimal di RSUD
Encik Mariyam Kabupaten Lingga. Penelitian ini menggunakan
desain penelitian deskriptif kualitatif. Penelitian ini dilaksanakan
pada bulan September 2021 di RSUD Encik Mariyam Kabupaten
Lingga, informan dalam penelitian ini berjumlah 4 orang yang
terdiri dari 1 orang Direktur Rumah Sakit, 1 orang Kepala Instalasi
Rekam Medis, 1 orang CSO dan 1 orang pegawai bagian
penyimpanan. Pengumpulan data dengan wawancara secara
mendalam dan observasi. Kesimpulannya masih kekurangan
petugas/SDM bagian rekam medis, Standar Operasional Prosedur
(SOP) pengelolaan berkas rekam medis sudah ada tapi ada
kegiatan yang belum dilakukan sesuai SOP, Sarana/Prasarana
yang mendukung dalam pengelolaan berkas rekam medis yang
belum memadai seperti belum ada KIUP, Fasilitas fisik
penyimpanan ketersediannya kurang, karena berkas selalu
bertambah-tambah, Pengelolaan rekam medis sering terhambat
karena gangguan jaringan untuk memproses SIMRS, dan dalam
pengembalian berkas kurang lengkap dan tidak tepat waktu. Saran
dari penelitian perlu adanya peningkatan SDM, penyesuaian SOP,
penambahan Sarana Prasarana dan fasilitas fisik penyimpanan
agar kegiatan pengelolaan berkas rekam medis berjalan optimal.

 

Medical Record is a file that contains records and documents regarding patient identity, examination, treatment, other medical actions at health service facilities for outpatient, inpatient, both managed by the government and the private sector. The problems found in the Encik Mariyam Hospital, Lingga Regency, have carried out medical record activities, but the management of medical records has not run optimally. This study aims to analyze the causes of the unimplemented optimal management of medical records in Encik Mariyam Hospital, Lingga Regency. This study used a qualitative descriptive research design. This research was carried out in September 2021 at the Encik Mariyam Hospital, Lingga Regency, the informants in this study were 4 people consisting of 1 Hospital Director, 1 Head of Medical Record Installation, 1 CSO and 1 storage employee. Data collection by in-depth interviews and observations. The conclusion is that there is still a shortage of officers/HR for the medical record section, Standard Operating Procedures (SOP) for managing medical record files already exist but there are activities that have not been carried out according to SOPs, Facilities/Infrastructure that support the management of medical record files are inadequate such as the absence of KIUP, Facilities physical storage availability is lacking, because files are always increasing, medical record management is often hampered due to network disturbances to process SIMRS, and file returns are incomplete and not on time. Suggestions from the research need to increase human resources, adjust SOPs, add infrastructure and physical storage facilities so that medical record file management activities run optimally.

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Published

2022-04-30

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