GAMBARAN PENGELOLAAN DOKUMEN REKAM MEDIS DI PUSKESMAS CIPONDOH KOTA TANGERANG
DOI:
https://doi.org/10.53625/jirk.v1i3.187Keywords:
Document Management, Medical Records, Cipondoh Health CenterAbstract
Medical records are one of the units in the puskesmas whose existence is quite important. Medical records contain records of patient data that are of legal value and can affect the quality of health services. Management of medical record documents to achieve the establishment of administrative order and health services in Cipondoh Health Center, Tangerang City. The management of medical record documents is needed as one of the health care facilities. Cipondoh Health Center tangerang city has 5 medical records officers. Medical records officers who have a background in medical records are only 1 person. Officers at TPP (Patient Registration Center) sometimes do not convey the rights and obligations of patients, where the information is important to the patient. The purpose of this study is to describe the management of medical record documents in cipondoh health center in order to create an orderly admnistrasi and health services. The result of this study is that the management system of medical record documents has been conducted sequentially and systematically. However, there are some things in the management of medical records that are not in accordance with the operational standards of puskesmas procedures, regulations, and theories. The medical records officer does not yet have a clear description of the task so concurrently the task. The design of the form is in accordance with the theory. There are incomplete medical records such as filling out diagnoses, diagnostic codes, and doctor's initials. the purpose of the researchers here to describe the management of medical record documents in cipondoh health center Tangerang City. The advice that can be given is in coding the diagnosis of the disease, it should be done by opening the ICD-10 book so that the patient's diagnostic code becomes accurate
References
Budi, Savitri Citra. (2011). Manajemen Unit Rekam Medis. Yogyakarta: Quantum Sinergis Media
Dindatia, Novi; Junaid; Rasama. 2017. Gambaran Kinerja Petuga Rekam Medik di Rumah Sakit Umum Daerah Kota Kendari Tahun 2017. Jurnal Ilmiah Mahasiswa Kesehatan Masyarakat Vol 2 No 6
Giyana, F. 2012. Analisis Sistem Pengelolaan Rekam Medis Rawat Inap Rumah Sakit Umum Daerah Kota Semarang. Jurnal Kesehatan Masyarakat Vol 1 No 2.
Departemen Kesehatan Republik Indonesia Direktorat Jendral Pelayanan Medik. 1997. Pedoman Pengelolaan Rekam Medis Rumah Sakit di Indonesia. Jakarta: Departemen Kesehatan Republik Indonesia. 1997.
Peraturan Menteri Kesehatan No. 269 Tahun 2008 Tentang Rekam Medis.
Peraturan Menteri Kesehatan No. 75 Tahun 2014 Tentang Pusat Kesehatan Masyarakat.
Neuman, W. L. (2003). Social Research Methods, Qualitative and Quantitative Approaches. Fifth Edition. Boston: Pearson Education.
Peraturan Menteri Kesehatan Republik Indonesia Nomor 43 Tahun 2019 Tentang Pusat Kesehatan Masyarat.
Devhy, Ni Luh Putu. (2019). Analisis Kelengkapan Rekam Medis Rawat Inap Rumah Sakit Ganesha di Kota Gianyar Tahun 2019. Jurnal Rekam Medis dan Informasi Kesehatan, 2 (2), 106 – 110.
Garmelia, Elise. (2019). Tinjauan Ketepatan Koding Penyakit Gastroenteritis Pada Pasien BPJS Rawat Inap di UPTD RSUD Kota Salatiga. Jurnal Rekam Medis dan Informasi Kesehatan, 2 (2), 84 – 90.
Harjanti. (2019). Identifikasi Penerapan Family Numbering Sistem di Puskesmas Wilayah Dinas Kesehatan Kota Surakarta. Jurnal Rekam Medis dan Informasi Kesehatan. 2 (2), 60 – 64.
Hatta, Gemala R. (2014). Pedoman Manajemen Informasi Kesehatan di Sarana Pelayanan Kesehatan. Jakarta: Universitas Indonesia (UI-PRESS).
Nuraini, Novita. (2015). Analisis Sistem Penyelenggaraan Rekam Medis di Instalasi Rekam Medis RS “X” Tangerang Periode April – Mei 2015. Jurnal ARSI, 1 (3), 147 – 158.
Putri, Wahyuana Amelia. (2019). Faktor Penyebab Missfile Pada Berkas Rekam Medis di Rumah Sakit. Jurnal Manajemen Informasi Kesehatan Indonesia, 7 (2), 137 – 140.
Setiadani, Priaji. (2016). Faktor-faktor yang Berhubungan dengan Mutu Rekam Medis Pasien Rawat Inap di RSUD DR. Moewardi Surakarta. Nexus Kedokteran Komunitas, 5 (1), 54-68.
Suhartina, Ina. (2019). Analisis Efektivitas SOP Pelaksanaan Penyimpanan Berkas Rekam Medis di Puskesmas Lawang. Jurnal Manajemen Informasi Kesehatan Indonesia, 7 (2), 121 – 128.
Sudra, Rano Indradi. (2014). Rekam Medis. Tanggerang Selatan: UI.
Talib, Thabran. (2018). Analisis Beban Kerja Tenaga Filing Rekam Medis (Studi Kasus Rumah Sakit Ibu dan Anak Bahagia Makassar). Jurnal Manajemen Informasi Kesehatan Indonesia, 6 (2), 123-128.
Widjaja, Lily. (2018). Pengaruh Kepuasan Terhadap Kelengkapan Rekam Medis di Rumah Sakit Umum Daerah Adjidarmo. Jurnal Manajemen Informasi Kesehatan Indonesia, 6 (1), 37 – 40.
Departemen Kesehatan Republik Indonesia Direktorat Jendral Pelayanan Medik. 2006. Pedoman Pengelolaan Rekam Medis Rumah Sakit di Indonesia. Jakarta: Departemen Kesehatan Republik Indonesia. 2006.
Departemen Kesehatan Republik Indonesia Direktorat Jendral Pembinaan Kesehatan Masyarakat. 1997. Petunjuk Pengisian Formulir Pencatatan SP2TP. Jakarta: Departemen Kesehatan Republik Indonesia. 1997.
