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All Journal JURNAL ILMIAH SIMANTEK JURNAL ILMIAH KOHESI
CHANDRA, ISKANDAR
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ANALISIS PELAKSANAAN PENYIMPANAN DAN PENGAMBILAN DOKUMEN REKAM MEDIS BAGIAN FILING DI RS USU CHANDRA, ISKANDAR
JURNAL ILMIAH SIMANTEK Vol 5 No 3 (2021): JURNAL ILMIAH SIMANTEK
Publisher : LP2MTBM MAKARIOZ

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Abstract

This research aims to determine the implementation of storing and returning medical record documents at Usu Hospital. This research is a descriptive research/qualitative approach. Determination of informants was carried out using purposive sampling. The informants in this study were the head of medical records and the medical records officer. Data collection by observation, interviews and documentation. The results of the research show that the management of medical record data at the North Sumatra Hospital in Medan is: First, making medical records, namely filling out forms for new patients, while old patients only show their treatment cards to be searched for medical record status by the filling officer manually. Second, Medical Record Storage (Filling), namely receiving files that are complete and arranged using a centralized system and using a direct numbering system for the time required to retrieve medical record files, namely 10-20 minutes. Third, destruction of medical records, which is carried out if the patient has not come for five years, is destroyed by shredding inactive files and then burning them. Fourth, maintaining the confidentiality of medical records, namely the custody of medical record files only allows medical record officers with legal interests. So the management of outpatient medical record data at USU Hospital has been carried out in accordance with Minister of Health Regulation Number 269/MENKES/KES/III/2008.
ANALISA KETIDAKTEPATAN WAKTU PENGEMBALIAN BERKAS REKAM MEDIS RAWAT INAP DI RUMAH SAKIT UMUM SUNDARI MEDAN CHANDRA, ISKANDAR
JURNAL ILMIAH KOHESI Vol 6 No 4 (2022): JURNAL ILMIAH KOHESI
Publisher : LP2MTBM MAKARIOZ

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Background: Returning medical records is the process of taking medical records from the borrowing service unit back to the medical records unit. Based on a preliminary study carried out at the medical records installation at RSU Sundari Medan, it is known that there are still medical record files whose returns are not on time or within 2x24 hours. Objective: To analyse the inaccurate time for returning medical record files from the inpatient room to the medical records installation and to determine the factors causing the inaccurate time for returning inpatient medical record files at RSU Sundari Medan. Research Method: The research used is descriptive research, namely describing the analysis of data collection on inaccurate times for returning inpatient record files to the medical records installation at Sundari RSU Medan. Results: Based on the results of the analysis of 2280 patient medical record files at RSU Sundari Medan, the percentage of timely return of medical record files was 46%, and the inaccurate time of return of medical record files was 54%. Factors that cause inaccurate returns of inpatient medical record files are incomplete filling out of medical record files, especially in medical resume forms, such as incomplete diagnoses and Dr. signatures, and a and a lack of communication and training regarding the correct time for returning medical record files.
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