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

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.