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ANALISA ASPEK KEAMANAN DAN KERAHASIAAN DOKUMEN REKAM MEDIS DI RUANG FILING RUMAH SAKIT VINA ESTETICA TAHUN 2020 KABAN, PEBERIWATI BR
JURNAL ILMIAH KOHESI Vol 6 No 4 (2022): JURNAL ILMIAH KOHESI
Publisher : LP2MTBM MAKARIOZ

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Abstract

Medical Record Document (DRM) is a tool to record, recording the transactions, Quality of service can be enhanced when supported by the safety and confidentiality of medical record patient in the storage room. Security and confidentiality of medical records in RS Vina Estetica were still not going well. Still found leaking roof space of filing, shelving humid, dusty, absence of camphor, the door is often not locked, still found the patient requests their own medical record and bring the document it self, and document medical records piled up on the floor. The main problems were the lack of procedures of security and confidentiality of medical records document. Therefore, reseacher wanted to describe aspects of security and confidentiality the medical record documents on filing unit in RS Vina Estetica. This study was a descriptive, cross-sectional approach and methods were observation and interviews. Subjects were filing officer as many as five people, and object was the security and confidentiality of medical records in Filing. The research instrument used were guidelines for observation, interview and gauge the temperature of the moisture. Data processing is editing, tabulation, and data presentation. Based on the observation of security medical records processing in filing RS Vina Estetica can be seen from the physical aspect was still not safe from the dangers of fire, and flood, in terms of biological not use camphor on each shelf, and in terms of chemical officers were still doing activities such as eating and drinking in the filing room. From the aspect of confidentiality, unlocked door and patients or staff other than medical record personel enter the filing room. There was no policies or standard operating procedures governing the security and confidentiality of medical records document. To maintain the security and confidentiality of medical records document, it needs facilities and infrastructure and the rooms were quite safe and good for maintaining confidentiality medical records document. Policies and procedures need to be made that contains rules in providing good service.
ANALISIS PENGEMBALIAN BERKAS REKAM MEDIS RAWAT INAP GUNA MENGHITUNG KETIDAKTEPATAN BERKAS REKAN MEDIS DI RUMAH SAKIT UMUM SUNDARI MEDAN KABAN, PEBERIWATI BR
JURNAL ILMIAH KOHESI Vol 6 No 4 (2022): JURNAL ILMIAH KOHESI
Publisher : LP2MTBM MAKARIOZ

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Abstract

Returning medical records is the initial activity of processing patient medical record files before proceeding to the next stage. This study aims to determine the quality standards for returning medical record files for inpatients at RSU Sundari Medan, return time, delay time and factors causing delays in returning medical records. The research was conducted at RSU Sundari Medan using a mixed methods approach. Data collection was carried out from January to March 2021, using secondary data originating from 985 medical record files based on documentation of the return of inpatient medical record files in February 2021 and primary data originating from interviews. Data were processed using programs, spreadsheets, with univariate analysis. The research result of returning medical records is a process of taking medical records from the borrowing service unit back to the medical records unit. Return of medical record documents is declared late if it exceeds the return time limit, which is a maximum of 2 x 24 hours. After the patient is discharged from the hospital. The rate of delays in returning medical record files from January to March 2021 reached 58%. The causes of delays are influenced by the doctor's discipline in filling out the patient's resume, incomplete documents in the patient's status, and human resources.