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All Journal Jurnal Kesehatan Health Information : Jurnal Penelitian Community Development Journal: Jurnal Pengabdian Masyarakat J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan MAHESA : Malahayati Health Student Journal PELS (Procedia of Engineering and Life Science) International Journal of Public Health Excellence (IJPHE) Holistik Jurnal Kesehatan
Yektiningtyastuti Yektiningtyastuti
Stikes Al-Irsyad Cilacap
Humanities Computer Science & IT Control & Systems Engineering Dentistry Economics, Econometrics & Finance Education Electrical & Electronics Engineering Engineering Health Professions Medicine & Pharmacology Nursing Public Health

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Studi Komparatif : Perbandingan Pengelolaan Rekam Medis pada Rumah Sakit di Hospital Sultan Abdul Aziz Shah Malaysia dan RSUD Cilacap Amti, Nicky Putri Karla Dwi; Yektiningtyastuti, Yektiningtyastuti; Sari, Arum Astika; Rahim, Norizanne Binti Abd; Pratama, Riskrisna Adi
MAHESA : Malahayati Health Student Journal Vol 6, No 5 (2026): Volume 6 Nomor 5 (2026)
Publisher : Universitas Malahayati

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33024/mahesa.v6i5.24822

Abstract

ABSTRACT Medical record management is a crucial component of hospital service systems because it ensures continuity of care, information security and the improvement of healthcare service quality. The advancement of digitalization has encouraged hospitals to transition from manual systems to electronic medical records. However, the implementation varies across institutions and countries. This study aims to compare medical record management at Hospital Sultan Abdul Aziz Shah Malaysia and RSUD Cilacap Indonesia, based on six aspects: unit structure, management system, quality standards, regulatory framework, borrowing and returning mechanisms and the level of digitalization. This study employed a qualitative methodology with a comparative descriptive design. Data were collected through direct observation, documentation review including standard operating procedures (SOP) and flowcharts, as well as literature and regulatory analysis. The data were analyzed using qualitative comparative analysis through data reduction, data presentation in narrative form and comparative tables, and source triangulation. The findings indicate differences across the six examined aspects. Hospital Sultan Abdul Aziz Shah Malaysia has a specialized medical record unit and refers to ISO 9001:2015 and internal policies, while RSUD Cilacap integrates medical record management with clinical services and insurance claims, referring to Permenkes No.24/2022 and LARS DHP 2022 accreditation standards. Both hospitals implement a hybrid system combining manual and electronic records, although the scope of digitalization and document control system differs. These differences indicate that regulatory frameworks, organizational structures, and digital readiness influence medical record management practices and their implications for hospital service quality. Keywords: Comparison, Digitization, Electronic Medical Record, Medical Record Management, Service Quality.  ABSTRAK Pengelolaan rekam medis merupakan komponen penting dalam sistem pelayanan rumah sakit karena berperan dalam menjamin kesinambungan pelayanan, keamanan informasi dan peningkatan mutu layanan kesehatan. Perkembangan digitalisasi mendorong rumah sakit beralih dari sistem manual menuju rekam medis elektronik, namun implementasinya menunjukkan variasi antar institusi dan negara.Penelitian ini bertujuan membandingkan pengelolaan rekam medis di Hospital Sultan Abdul Aziz Shah Malaysia dan RSUD Cilacap Indonesia berdasarkan enam aspek yaitu struktur unit, sistem pengelolaan, standar mutu, regulasi, mekanisme, peminjaman dan pengembalian, serta tingkat digitalisasi. Penelitian ini menggunakan metodologi kualitatif dengan desain deskripsi komparatif. Data dikumpulkan melalui observasi langsung, studi dokumentasi (SPO/Flowchart) serta telaah literatur dan regulasi, kemudian dianalisis melalui reduksi data, penyajian data dalam bentuk narasi dan tabel perbandingan, serta triangulasi sumber. Hasil Penelitian menunjukkan adanya perbedaan pada enam aspek yaitu Hospital Sultan Abdul Aziz Shah Malaysia memiliki unit rekam medis terspesialisasi dan mengacu pada ISO 9001:2015 serta kebijakan internal, sedangkan RSUD Cilacap terintegrasi dengan layanan dan klaim, beracuan Permenkes 24/2022 dan LARS DHP 2022. Keduanya menerapkan sistem hybrid, namun cakupan digitalisasi dan sistem kontrol berkas berbeda. Perbedaan tersebut menunjukkan bahwa konteks regulasi, organisasi dan kesiapan digital memengaruhi praktik pengelolaan rekam medis serta implikasinya terhadap mutu pelayanan rumah sakit. Kata Kunci: Digitalisasi, Mutu Pelayanan, Pengelolaan Rekam Medis, Perbandingan, Rekam Medis Elektronik.
Co-Authors AHMADI Aljufri, Salim Amalia, Pety Valeri Amalia, Pety Valeria Amsyah, Ummul Khairi Amti, Nicky Putri Karla Dwi Anggraeni, Okti Arsyada, Alin Sabrina Devita Elsanti Dion Romodon Elfirdausi, Tiara Eni Suprihatin Febrianti, Marni Gunawan Gunawan Hakim, Agya Osadawedya Happy Dwi Aprilina Harry Fauzi, Harry Ikhsan Mujahid Jennifa Jennifa, Jennifa Karmadani, Era Milania Kinasih, Shalsa Sekar Kusumawati, Khadija Librianty, Nurfanida Mukaromah, Citra Amiliana Mulyandari, Gesti Augina Nadi, Danu Tirta Prasetya, Fika Indah Pratama, Riskrisna Adi Prodia, Natalia Sabatyaningsih Putri, Chaesya Isnaeni Rahim, Norizanne Binti Abd Rasmita, Dina Reni Purwo Aniarti Rista Islamarida, Rista Rizki, Julia Nur Rosadi, Rahmat Sari, Arum Astika Sasmito, Priyo Syahda, Tiara Maulina Syuhada, Fatkhan Ummah, Shofiatul Willy Wijaya, Bernand Zahrasita Nur Indira