Patient data confidentiality may be compromised when the distribution of triage forms involves unauthorized individuals. A preliminary study at Hospital X found that triage forms and medical record files were still transported by patients' family members or relatives between the Emergency Department (ED) and the registration unit. This study aimed to evaluate the conformity of the triage-form distribution workflow with the hospital's Standard Operating Procedure (SOP) and to assess its implications for patient data confidentiality. A descriptive qualitative design was employed from June to July 2026 at the ED and registration/medical records unit. Nine informants who were directly involved in the distribution process were included using total sampling. Data were collected through interviews, direct observation, and review of the 2022 SOP for BPJS Emergency Patient Registration and were analyzed inductively through data reduction, display, and conclusion drawing. The findings showed that the SOP formally assigns medical record distribution to authorized staff; however, actual practice still involved patients' family members or relatives. Identified confidentiality risks included escorts who were not immediate family members, physical separation between the ED and registration area, temporary storage of forms in open areas, and the possibility of forms being lost or misplaced. The confidentiality risk was perceived to increase when the triage form became part of a complete medical record containing patient identity, diagnosis, and medical history. The study concludes that triage-form distribution at Hospital X in 2026 did not fully comply with the SOP and did not optimally safeguard patient data confidentiality. Implementation of Electronic Medical Records (EMR), stronger access control, and closer integration of registration and ED workflows are recommended.
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