Implementation of Inpatient Medical Records at dr. Reksodiwiryo Hospital: A Qualitative Study

Pelaksanaan Rekam Medis Rawat Inap di Rumah Sakit dr Reksodiwiryo: Studi Kualitatif

https://doi.org/10.53579/jitkt.v3i2.121

Authors

  • Mutia Rahmi Faculty of Public Health, Universitas Andalas
  • Ayulia Sari Faculty of Public Health, Universitas Andalas
  • Sri Siswati Faculty of Public Health, Universitas Andalas

Keywords:

hospital, hospitalization, medical record

Abstract

The objective of this study was to examine the implementation of medical records for hospitalized patients at dr. Reksodiwiryo Padang Hospital. The study employed a qualitative research methodology. Seven research informants were selected using the purposive sampling technique. Data were gathered through the utilization of in-depth interviews, on-site observations, and scrutiny of documents. The Miles and Huberman model was employed for data analysis, encompassing reduction, display, and conclusion operations. The data validity test employed both source triangulation and method triangulation. According to the research findings on the input element, the quantity of medical record personnel was adequate and there was an existing standard operating procedure (SOP). However, there was a lack of dedicated budget and insufficient facilities and infrastructure. The procedural element of patient documentation, particularly in regard to the recording of admission and discharge sheets, was not fully completed. There was a delay in the submission of medical records, resulting in suboptimal medical record processing. An error occurred during the medical record storage process, resulting in a misfile. The implementation of Medical Records for Inpatients at dr. Reksodiwiryo Padang Hospital was suboptimal and required enhancement. It is advisable for the hospital to provide training sessions to enhance the proficiency of medical record officers and familiarize them with the existing Standard Operating Procedures (SOPs).

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References

Purba E. Analysis of Factors Causing Delay in Returning Medical Record Files from the Inpatient Installation to the Medical Record Installation Unit at Vina Estetica Hospital Medan for the period of May-July 2016. J Ilm Perekam Dan Inf Kesehat Imelda. 2016;1(2):111–9.

Nuraini N. Analisis Sistem Penyelenggaraan Rekam Medis di Instalasi Rekam Medis RS “X” Tangerang Periode April-Mei 2015. J Adm Rumah Sakit Indones. 2015;1(3):147–58.

Suryanto H. Analisis Sistem Penyelenggaraan Rekam Medis di Unit Rekam Medis Puskesmas Kota Wilayah Utara Kota Kediri. J Manaj Inf Kesehat Indones. 2020;8(2):113.

Sanggamale C, Kolibu FK, Maramis FRR. Analisis Pengelolaan Rekam Medis Di Rumah Sakit Umum Pancaran Kasih Manado. J KESMAS. 2018;7(4):1–11.

Gumilar RA, Herfiyanti L. Analisis Kelengkapan Rekam Medis Rawat Inap di Rumah Sakit Umum Bina Sehat Bandung. Cerdika J Ilm Indones. 2021;1(9):1192–9.

Rumah Sakit Reksodiwiryo Padang. Standar Prosedur Operasional (SPO) Rumah Sakit Reksodiwiryo Padang. Padang; 2018.

Menteri Kesehatan. Peraturan Menteri Kesehatan Republik Indonesia nomor 30 Tahun 2019 tentang Klasifikasi dan Perizinan Rumah Sakit. 2019;(1107):1–106.

Yuliana. Al Tamimi Kesmas ANALISIS PENGENDALIAN KEJADIAN SALAH SISIP DOKUMEN REKAM MEDIS DI RUMAH SAKIT ISLAM IBNU SINA PEKANBARU TAHUN 2018 Anastasya Shinta Yuliana (1) , Dedi Afandi (2) , Arief Wahyudi (3) (1). J Public Heal Sci [Internet]. 2018;7:99–100. Available from: http://jurnal.alinsyirah.ac.id/index.php/kesmas

Swari SJ, Alfiansyah G, Wijayanti RA, Kurniawati RD. Analisis Kelengkapan Pengisian Berkas Rekam Medis Pasien Rawat Inap RSUP Dr. Kariadi Semarang. Arter J Ilmu Kesehat. 2019;1(1):50–6.

Nabilla DR, Hasin A. Analisis Efektivitas Penerapan Standard Operating Procedure (SOP) Pada Departemen Community &Academy RUN System (PT Global Sukses Solusi Tbk). Sel Manaj J Mhs … [Internet]. 2022;01(06):58–75. Available from: https://journal.uii.ac.id/selma/article/view/26602%0Ahttps://journal.uii.ac.id/selma/article/download/26602/14474

Sari RY, Suprapti E, Solechan A. Pengaruh Sosialisasi SOP APD dengan Perilaku Perawat dalam Penggunaan APD (Handscoon, Masker, Gown) di RSUD Dr.H. Soewondo. Keperawatan Dan Kebidanan. 2019;1–10.

Navis D, Sulaeman S, Ahmad G, Rustiana SH. Pengaruh Kepemimpinan, Kompetensi Tenaga Kesehatan, Sarana Prasarana terhadap Mutu Pelayanan Serta Dampaknya pada Kepuasan Pasien Rawat Inap di Puskesmas Leuwisadeng. Muhammadiyah Public Heal J. 202AD;I(I):32–41.

Allpandianto S. Tinjauan Kelengkapan Rekam Medis pada Pasien Tuberkulosis di Rumah Sakit Tk IV DKT Madiun. Stikes Bhakti Husada Mulia Madiun; 2021.

Budi SC. Manajemen Unit Kerja Rekam Medis. Yogyakarta: Quantum Sinergis Media; 2011.

Hananto S, Kun K. Tinjauan Penggunaan Sistem Penjajaran DRM dengan Metode SNF (Straight Numerical Filling) di Filling Rumah Sakit Islam Muhammadiyah Kendal. 2013;

Djohar D, Oktavia N, Damayanti FT. Analisis Penyebab Terjadinya Missfile Dokumen Rekam Medis Rawat Jalan di Ruang Penyimpanan(Filling) RSUD Kota Bengkulu Tahun 2017. J Manaj Inf Kesehat Indones. 2018;6(2):79.

Giyana F. Analisis Sistem Pengelolaan Rekam Medis Rawat Inap Rumah Sakit Umum Daerah Kota Semarang. Universitas Diponegoro; 2012.

Published

2023-12-14

How to Cite

Rahmi, M., Sari, A., & Siswati, S. . (2023). Implementation of Inpatient Medical Records at dr. Reksodiwiryo Hospital: A Qualitative Study: Pelaksanaan Rekam Medis Rawat Inap di Rumah Sakit dr Reksodiwiryo: Studi Kualitatif. JURNAL ILMU DAN TEKNOLOGI KESEHATAN TERPADU, 3(2), 67–77. https://doi.org/10.53579/jitkt.v3i2.121