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GAMBARAN PENGEMBALIAN DOKUMEN REKAM MEDIS RAWAT INAP RUANG VII TRIWULAN IV TAHUN 2013 DI RUMAH SAKIT UMUM DAERAH TASIKMALAYA Ulfah Fauziah; Ida Sugiarti
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 2, No 1 (2014)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/.v2i1.42

Abstract

ABSTRACTThe purpose of the research is to know the plots of returning of medical recording document of hospitalizingat RSUD Tasikmalaya that is suitable with the SOP, to know the plots of returning the medical recordingdocument of hospitalizing at RSUD Tasikmalaya that is not suitable with SOP, to know the descriptionofreturning the medical recording unit which was late from room VII in 2013 at RSUD Tasikmalaya and to knowthe description of returning the medical recording document of hospitalizing from the ward to the medicalrecording unit which was on time from room VII in 2013 at RSUD Tasikmalaya.The kind of research is descriptive by retrospective approach, the method is gathering data observation.Population and sample of this research are 714 sample of medical recording document of hospitalizing at roomVII and about 256 sample of medical recording document at room VII by using random sampling technique.The data analysis is used univariate analysis.The result of the research shows that the returning of medical recording document of hospitalizing at roomVII with the higher percentages of the returning of medical recording unit on time is in October as much as78,82% from the 67 documents and higher percentage of the late returning of medical recording is in Decemberas much as 84,88% from the 73 the total of the documents.In general, the returning of medical recording document of hospitalizing at room VII is equal with the plots ofthe returning of medical recording document, the maximum time is used for the returning of medical recordingis about 14 days.The key words: The late of returning of medical recording document
ANALISIS KELENGKAPAN PENGISIAN DATA FORMULIR ANAMNESIS DAN PEMERIKSAAN FISIK KASUS BEDAH Rd. Irda Melinda Febriyanti; Ida Sugiarti
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 3, No 1 (2015)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/.v3i1.67

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AbstractQuantitative analysis has conducted in dr. Slamet Garut General Hospital, but there are still anamnesis andphysical examination forms are incomplete both clinical data and demographic data. Based on the highestpreliminary survey of incompleteness on the register component is 83.34%. The aim of this research is toknow the fulfilment procedure, completeness and incompleteness data fulfilment of anamnesis and physicalexamination forms. The method that used in this research is observation quantitative analysis, using instrumentobservation sheet. The population in this research are 1008 medical record documents on semester I in 2013.The magnitude of the sample uses Slovin formula is 90 documents. Slovin formula is used because it refersto large samples which are 90 documents. The result of research showed that complete form anamnesis andphysical examination of the patient identification component is 20%, important report is 31.12%, authenticationis 83.33% dan the register is 3.34%. Refers to the minimum standard of completeness which is submitted bythe department of health (2006), the completeness document must be 100%. It can be conclusion that theanamnesis and physical examination data fulfilment in dr. Slamet Garut General Hospital is not complete.Preferably, socialization is needed in fulfilment medical record document which is adapted to the StandardOperational Procedure (SOP) or The Fixed Procedure (PROTAP) which is adapted to all units related personalhealth such as doctors, nurses, dan medical record officer.Key words : Completeness, Filling up data, Anamnesis and physical examination.AbstrakDi RSUD dr. Slamet Garut sudah dilakukan analisis kuantitatif tetapi masih terdapat formulir anamnesisdan pemeriksaan fisik yang kurang lengkap baik data demografi maupun data klinis. Berdasarkan surveypendahuluan ketidaklengkapan yang tertinggi pada komponen pencatatan 83,34%. Tujuan penelitian ini untukmengetahui prosedur pengisian, kelengkapan dan ketidaklengkapan pengisian data formulir anamnesis danpemeriksaan fisik. Penelitian ini menggunakan metode analisis kuantitatif yaitu observasi, dengan menggunakaninstrumen lembar observasi. Populasi dalam penelitian ini sebanyak 1008 dokumen rekam medis padasemester I tahun 2013. Besarnya sampel menggunakan rumus Slovin sebanyak 90 dokumen. Hasil penelitianmenunjukan kelengkapan formulir anamnesis dan pemeriksaan fisik komponen identifikasi pasien sebanyak20%, laporan penting 31,12%, authentikasi 83,33% dan pencatatan 3,34% . Mengacu pada standar minimalkelengkapan dokumen yang diajukan departemen kesehatan (2006) kelengkapan dokumen harus 100%.Maka dapat disimpulkan pengisian data formulir anamnesis dan pemeriksaan fisik di RSUD dr. Slamet Garuttidak lengkap. Sebaiknya, diadakan sosialisasi dalam pengisian dokumen rekam medis disesuaikan denganStandar Operasional Prosedur (SOP) atau Prosedur Tetap (PROTAP) yang telah ditetapakan pada semua unitpelayanan kepada tenaga kesehatan terkait seperti : dokter, perawat dan petugas rekam medis.Kata Kunci: Kelengkapan, Pengisian data, Anamnesis dan Pemeriksaan Fisik
Kelengkapan Pengisian Formulir Laporan Operasi Kasus Bedah Obgyn Sebagai Alat Bukti Hukum Listia Nur Febrianti; Ida Sugiarti
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 7, No 1 (2019)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/jmiki.v7i1.213

Abstract

According to the Ministry of Health Decree No. 129 of 2008 concerning Minimum Standards Services in Hospitals, filling medical record include surgery report forms must be 100% that can be used as legal evidence. Preliminary study addressing 10 surgery report form of obgyn surgery cases in December 2017 wasn’t filled complete. Knowing how the implementation filling of the surgery report form of obgyn surgery cases as a legal evidence in RSUD Ciamis  District Ciamis in quarter IV 2017. Methods: Descriptive with mixed method approach, a total sample is 82 surgery report forms, and the research informant is a obgyn surgeon, coordinator of administration and medical record service, and surgical nurse. The average percentage of completeness surgery report forms of the general surgery cases in the IV quarter of 2017 was 63,78%. Inhibitory factors are limited time, patient quantity, delay in medical record control, too much items filled of form. Average percentage of surgery report form filling still below the Minimum Standards Services. Hospital should improve the causal factors that inhibit the incompleteness of surgery report form.
FAKTOR-FAKTOR KETERLAMBATAN PENGEMBALIAN SENSUS HARIAN RAWAT INAP DI RSUD KAB. CIAMIS Firman Cahya Diningrat; Ida Sugiarti
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 3, No 2 (2015)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/.v3i2.84

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AbstractThe implementation of good medical records will support the implementation of health improvement services in hospital, one of them is making report based on the daily census. The return of daily hospitalizazion census to the medical record unit in RSUD Kab. Ciamis is often delayed. This research aims to know the factors of delay returns daily census of hospitalizazion to medical record unit at RSUD Kab. Ciamis. The method used in this research is qualitative method with phenomenological approach. The data collecting used interview and observation techniques in 8 informants. Data analysis is done by the data reduction, data presentation and withdrawal data conclusion or verification. Based on this research, it is known that the daily census has been delayed for two weeks, it is incompatible with the standard operating procedures (SOP) in which the daily census should have sent to the Medical Records back at least at 09.00 am the next day. The cause of the delay returns daily census is the lack of responsibility of the officer and the mismatch workload which is resulting in low productivity of labour. It is necessary for the holding of related SOP socialization census data collection daily hospitalization for officers, especially for the nurses in the implementation mechanism census daily data.Keyword: Delays, Returns, Census, HospitalizationAbstrakPenyelenggaraan rekam medis yang baik akan menunjang terselenggaranya peningkatan pelayanan kesehatan di rumah sakit, salah satunya adalah pembuatan laporan berdasarkan sensus harian. Pengembalian sensus harian rawat inap ke unit rekam medis di RSUD Kab. Ciamis sering mengalami keterlambatan. Penelitian ini bertujuan untuk mengetahui faktor-faktor keterlambatan pengembalian sensus harian rawat inap ke unit rekam medis di RSUD Kab. Ciamis. Metode yang digunakan dalam penelitian ini adalah metode kualitatif dengan pendekatan fenomenologi. Pengumpulan data menggunakan teknik wawancara dan observasi pada delapan informan. Analisis data yang dilakukan adalah dengan cara reduksi data, penyajian data serta penarikan data simpulan atau verfikasi. Berdasarkan hasil penelitian diketahui bahwa sensus harian mengalami keterlambatan selama dua minggu, hal tersebut tidak sesuai dengan standar operasional prosedur (SOP) dimana sensus harian harus dikembalikan ke bagian Rekam Medis paling lambat jam 09.00 WIB hari berikutnya. Penyebab dari keterlambatan pengembalian sensus harian adalah kurangnya tanggung jawab petugas dan ketidaksesuaian beban kerja sehingga mengakibatkan rendahnya produktivitas kerja. Untuk itu perlu diadakannya sosialisasi terkait SOP pengumpulan data sensus harian rawat inap untuk petugas, utamanya untuk perawat dalam mekanisme pelaksanaan sensus data harian.Kata Kunci : Keterlambatan, Pengembalian, Sensus, Rawat Inap
Prosedur dan Jenis Permintaan Visum et Repertum di Rumah Sakit: Literature Review Dies Puji Ramadhani; Ida Sugiarti
Indonesian of Health Information Management Journal (INOHIM) Vol 9, No 2 (2021): INOHIM
Publisher : Lembaga Penerbitan Universitas Esa Unggul

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47007/inohim.v9i2.302

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AbstractVisum et repertum (VeR) is a medical certificate used for judicial needs in the form of a written report made by a doctor containing the results of the examination. VeR is one of the five legal pieces of evidence in court. Making a VeR that is not following hospital procedures can lead to the submission of evidence in court proceedings. This study aims to determine the standard procedure for implementing medical information for VeR and the types of cases for which a VeR is requested. This type of research is a literature review using Google Scholar and Garuda databases with a boolean system strategy. The flow of the implementation of patient medical information for VeR begins with the police submitting a letter of request for VeR to the hospital administration by bringing the requirements of an official request letter from the director of the hospital. The visa request letter and the report are placed in the Medical Record Installation for further processing by the Medical Record. The types of cases requested for VeR are divided into two, namely for living victims and dead victims. Living victims are divided into injuries, sexual crimes, and psychiatric.Keywords: literature review, visum et repertum (VeR), fixed procedure, type of request. AbstrakVisum et repertum (VeR) merupakan surat keterangan medis yang sifatnya dipergunakan untuk kebutuhan peradilan berupa laporan tertulis yang dibuat oleh dokter yang memuat hasil pemeriksaan. Visum et Repertum merupakan salah satu dari lima alat bukti yang sah di pengadilan. Pembuatan visum et repertum yang tidak sesuai dengan prosedur tetap rumah sakit dapat menghambat penyampaian bukti dalam proses pengadilan. Penelitian bertujuan untuk mengetahui prosedur tetap pelaksanaan pelepasan informasi medis untuk keperluan visum et repertum serta jenis permintaan visum et repertum. Jenis penelitian adalah literature review menggunakan database Google Scholar dan Garuda dengan strategi boolean system. Alur pelaksanaan pelepasan informasi medis pasien untuk keperluan visum et repertum dimulai dengan pihak kepolisian menyerahkan surat permintaan visum et repertum ke bagian tata usaha Rumah Sakit dengan membawa persyaratan surat permohonan resmi dari kepolisian kepada direktur Rumah Sakit. Surat permintaan visum et repertum tersebut didisposisikan ke Instalasi Rekam Medis untuk selanjutnya diproses. Jenis kasus yang dimintakan visum et repertum dibagi menjadi dua, yaitu untuk korban hidup dan korban mati. Korban hidup terbagi menjadi perlukaan, kejahatan seksual, dan psikiatrik.Kata Kunci: literature review, visum et repertum, prosedur tetap, jenis permintaan
Faktor-Faktor Kelengkapan Informed Consent Menggunakan Metode Fishbone Untuk Menunjang Mutu Rekam Medis Sylda Namara Rizkika; Ida Sugiarti
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 10, No 2 (2022)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/jmiki.v10i2.445

Abstract

Ketidaklengkapan informed consent berdampak kepada kualitas mutu rekam medis. Penilaian kelengkapan informed consent dilakukan melalui analisis kuantitatif. Faktor kelengkapan informed consent dapat dianalisis menggunakan unsur manajemen. Penelitian dilakukan untuk menemukan faktor kelengkapan informed consent menggunakan unsur 5M dan metode fishbone. Jenis penelitian menggunakan metode literature review dari 16 jurnal menggunakan data sekunder dalam database Google Scholar dan strategi pencarian Kelengkapan OR Ketidaklengkapan OR Kuantitatif AND Informed Consent OR Persetujuan Tindakan Kedokteran NOT Rekam Medis dengan rentang waktu 2015-2020. Rata-rata kelengkapan informed consent 63%. Faktor kelengkapan informed consent berdasarkan literature yang dianalisis yaitu man (koordinasi petugas, kelalaian petugas, kesadaran petugas, kehadiran dokter, pemberian informasi, SDM, informed consent lisan dianggap mudah, pengetahuan, ketergantungan dokter, perhatian dokter, sikap dokter, kepatuhan, kesibukan, kondisi pasien), methods (penyelenggaraan rekam medis, keterkaitan SPO, prioritas pasien BPJS dan resiko tinggi, sosialisasi, evaluasi, tindak lanjut, akreditasi), materials (ketersediaan label, keterbacaan, ketersediaan bagian, bahasa dan kalimat, ketersediaan formulir), media (waktu, tempat), motivasi (punishment, reward).
Tinjauan Manajemen Informasi Dan Rekam Medis (MIRM) 11 Dan 14 Standar Nasional Akreditasi Rumah Sakit (SNARS) Di RSU X Tasikmalaya Tahun 2022 Novi Fidianti; Ida Sugiarti
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 7 No. 2 (2022): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v7i2.986

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Hospital accreditation is an acknowledgment of service quality. The results of a preliminary study in the filing room, the storage door was not locked because it was the access door to the medical record room, it was found that medical records were stored in cardboard boxes, storage of files stored in an untidy manner made medical records damaged and folded, and no tracer was available. The purpose of this study was to determine the application of security and confidentiality aspects of medical records according to MIRM 11 and 14. This type of research was qualitative with a phenomenological approach. The research subjects were 4 informants with data collection methods using in-depth interviews, observation, and documentation studies. Data analysis used thematic analysis. The results of the study provided SOP and SK for the prevention of unauthorized use of medical records. Protection from loss by recording in the register book. Protection from damage is to replace the cover, adequate facilities, and there are K3 officers. Protection from access interference is with officers always on guard at the storage room. The protection of the storage room against unauthorized access is that the door is always locked. There are SOP on the confidentiality and privacy of information. Regulations are enforced at the time of release of information and when accessing files. Other compliance officers comply with the time of returning medical records
Aspek Plan, Do, Check dan Act pada Pengendalian Waktu Tunggu Pelayanan Pasien Rawat Jalan Tiara Ayu Pratama; Ida Sugiarti
Jurnal Penelitian Kesehatan SUARA FORIKES Vol 13, No 4 (2022): Oktober 2022
Publisher : FORIKES

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33846/sf13439

Abstract

The standard waiting time for outpatient services as stipulated in the Decree of the Minister of Health is 60 minutes from the time the patient registers until he is received/served by a specialist. The waiting time for outpatient services describes how good and bad the quality of hospital services is. Therefore, the authors intend to determine the control of waiting time for outpatient services in hospitals by looking for Plan, Do, Check, and Act Aspects in the journal under study. Literature study using Google Scholar, Garuda, and PubMed as databases, and Boolean System as a search strategy. The number of literature that went through the synthesis stage was 712 and 17 kinds of literature were taken based on the results of inclusion and exclusion. The planning aspect of this study was the 60-minute waiting time. Aspects include adding human resources, improving staff discipline, making and optimizing standard operating procedures, and adding infrastructure. The examination aspect found that the waiting time for outpatient services had been largely reduced. Aspects of the Act explain that controls that do not affect the reduction of waiting times are not reused.Keywords: hospital service quality; PDCA method: waiting time ABSTRAK Standar waktu tunggu pelayanan pasien rawat jalan berdasarkan Standar Pelayanan Minimal adalah ≤ 60 menit terhitung sejak pasien mendaftar sampai diperiksa oleh dokter di poliklinik. Waktu tunggu pelayanan pasien rawat jalan menggambarkan baik dan buruknya mutu pelayanan rumah sakit. Oleh karena itu, penulis bermaksud untuk mengetahui pengendalian waktu tunggu pelayanan pasien rawat jalan di rumah sakit dengan mencari aspek Plan, Do, Check, dan Act pada jurnal yang diteliti. Studi literatur dengan menggunakan google scholar, garuda, dan PubMed sebagai database, dan Boolean System sebagai strategi pencarian. Jumlah literatur yang melalui tahap sintesis adalah 712, dan diambil 17 literatur berdasarkan hasil inklusi dan eksklusi. Aspek plan pada studi ini adalah waktu tunggu ≤ 60 menit. Aspek do terdiri dari menambah sumber daya manusia, meningkatkan kedisiplinan petugas, membuat dan mengoptimalkan standar prosedur operasional, serta menambah sarana prasarana. Aspek check menunjukan bahwa waktu tunggu poliklinik sebagian besar sudah berkurang. Aspek Act menyatakan bahwa pengendalian yang tidak mempengaruihi pengurangan waktu tunggu tidak digunakan kembali.Kata kunci: metode PDCA; mutu pelayanan rumah sakit; waktu tunggu
PENDAMPINGAN PENGELOLAAN REKAM MEDIS DAN INFORMASI KESEHATAN DI PUSKESMAS CIBEUREUM KOTA TASIMALAYA TAHUN 2021 idasugiarti; Arief Tarmansyah Iman; Fadil Ahmad Junaedi
Indonesian Journal of Health Information Management Services Vol. 1 No. 1 (2021): Indonesian Journal of Health Information Management Services (IJHIMS)
Publisher : APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (296.058 KB) | DOI: 10.33560/ijhims.v1i1.20

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Management of medical records and health information is one of the elements in the assessment of Public Health Center accreditation. Medical records play an important role in collecting accurate and comprehensive data for targeted health policies. The most appropriate management of medical records at the Public Health Center is the regional storage system or often referred to as the family folder system. Community service activities at the Cibeureum Health Center are carried out using consultation, training, and mentoring methods. Compiled 10 quality documents and the implementation of the e-family folder in stages. Furthermore, continuous data migration was carried out assisted by RMIK students. Activities carried out well.
Implementasi Manajemen Informasi Rekam Medis Berdasarkan Standar 8.4 Akreditasi Puskesmas di Puskesmas T Kota Tasikmalaya Anisa Isnaini; Ida Sugiarti
Indonesian of Health Information Management Journal (INOHIM) Vol 11, No 1 (2023): INOHIM
Publisher : Lembaga Penerbitan Universitas Esa Unggul

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47007/inohim.v11i1.409

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AbstractMinister of Health Regulation, 2015 number 46 of Primary Health Care Accreditation, is about recognizing independent institutions as administers accreditation by the Ministry of Health, held every three years after filling up the standards. Based on a preliminary study, T Primary Health Care had the first accreditation with the result of the 2017 Basic Status. Currently, T Public Health Center hasn't been re-accredited due to the impact of the Covid-19 pandemic. Medical record management is carried out by medical recorders in the special room, which is stored on shelves and boxes. There is a family medical record folder that still applies to personal medical records. T Primary Health Care stated that they had complete regulation because every two years routinely evaluated regulations and procedures, especially in the Management of medical records. The purpose of this study was to determine the alignment of the implementation of Medical Records Information Management (MIRM) in 8.4 Public Health Center Accreditation Standard for re-accreditation readiness by developing the quality of health services at T Primary Health Care in 2022. This research method used a case study approach with qualitative analysis. Result Research Organizing medical records in 8.4 standards of Medical Records Information Management (MIRM), T Public Health Center has tried to qualify the criteria. These include the available regulation and procedures related to the Management of Medical Records that are complete but haven't yet been ratified. As with each criterion, there are still discrepancies and obstacles in implementation. So the implementation of 8.4 standard Public Heath Center Accreditation is still not entirely by the regulations that have been made.Keywords: primary health care, primary health care accreditation, medical record managementAbstrakPeraturan Menteri Kesehatan Nomor 46 tahun 2015 menjelaskan Akreditasi Puskesmas merupakan pengakuan lembaga independen penyelenggara akreditasi ditetapkan oleh Menteri Kesehatan, setelah memenuhi standar yang diselenggarakan setiap 3 tahun. Berdasarkan studi pendahuluan Puskesmas T pernah melakukan akreditasi yang pertama dengan hasil status akreditasi dasar tahun 2017. Saat ini Puskesmas belum dilakukan re-akreditasi karena dampak pandemi Covid-19. Pengelolaan rekam medis dilakukan oleh Perekam Medis di ruang penyimpanan rekam medis yang disimpan pada rak dan kardus, memiliki map family folder tetapi masih menerapkan personal medical record. Puskesmas menyatakan regulasi telah lengkap, karena rutin melakukan evaluasi setiap dua tahun terkait Surat Keputusan (SK) dan Standar Prosedur Operasional (SPO) khususnya dalam pengelolaan rekam medis. Tujuan dilakukan penelitian untuk mengetahui pengelolaan keselarasan implementasi Manajemen Informasi Rekam Medis dalam standar 8.4 Akreditasi Puskesmas dalam kesiapan re-akreditasi sebagai upaya meningkatkan mutu pelayanan kesehatan di UPT Puskesmas T Tahun 2022. Penelitian digunakan dengan metode kualitatif pendekatan studi kasus. Hasil penelitian dalam penyelenggaraan rekam medis pada standar 8.4 Manajemen Informasi Rekam Medis, Puskesmas T telah berupaya memenuhi kriteria dalam standar tersebut. Diantaranya SK dan SPO terkait dengan pengelolaan rekam medis yang tersedia cukup lengkap, namun belum dilakukan pengesahan. Sebagaimana setiap kriteria masih terdapat ketidaksesuaian dan hambatan dalam pelaksanaanya. Sehingga implementasi dalam standar 8.4 Akreditasi puskesmas masih belum seluruhnya sesuai dengan regulasi yang telah dibuat.Kata Kunci: puskesmas, akreditasi puskesmas, pengelolaan rekam medis