The accreditation standard for Medical Record Information Management (MIRM) 13 regulates the provision of medical records. The regulation aims to ensure the continuity of patient health documentation. This study describes the condition of medical records starting from numbering, ordering, and making and retrieving medical records to support patient care documentation according to hospital accreditation standards in the MIRM chapter 13. This type of research is descriptive with a retrospective approach. The results showed that Panembahan Senopati Hospital Bantul already has Medical Record Service Guidelines and Standard Operating Procedures regulations. The regulation provides medical records for numbering, ordering, and creating and retrieving medical records to support patient service documentation. Panembahan Senopati Hospital Bantul implements an automated unit numbering system with the support of an RS SIM. They set the medical order after the patient goes home, both outpatient and inpatient. Making and retrieving medical records is part of implementing the unit numbering system. New patients make medical records when served at the registration section, while medical records take from the filing section for old patients. If medical records were not ready at the return visit, the professional HIM used a follow-up outpatient medical record form and combined it after the medical records were prepared. The regulation and the medical supply system show that Panembahan Senopai Hospital, Bantul, has implemented the MIRM standard 13 ep 1-5. However, implementation constraints are still on the MIRM 13 ep 4.Keywords: provision, numbering, assembling, retrieval, medical recordsAbstrakDalam standar akreditasi Manajemen Informasi Rekam Medis (MIRM) 13 mengatur penyediaan rekam medis. Rerulasi tersebut bertujuan menjamin kesinambungan dokumentasi kesehatan pasien. Penelitian ini bertujuan untuk menggambarkan penyediaan rekam medis mulai dari penomoran, urutan rekam medis, pembuatan dan retrieval rekam medis guna mendukung dokumentasi pelayanan pasien sesuai standar akreditasi rumah sakit pada bab MIRM 13. Jenis penelitian dekriptif dengan pendekatan retrospektif. Hasil penelitian menunjukkan bahwa RSUD Panembahan Senopati Bantul sudah memiliki regulasi berupa Pedoman Pelayanan Rekam Medis dan Standar Prosedur Operasional yang mengatur penyediaan rekam medis untuk penomoran, urutan rekam medis, pembuatan dan retrieval rekam medis guna mendukung dokumentasi pelayanan pasien. RSUD Panembahan Senopati Bantul menerapkan sistem penomoran unit yang sudah terotomatisasi dengan dukungan SIM RS. Pengaturan urutan rekam medis dilakukan setelah pasien pulang baik rawat jalan maupun rawat inap. Pembuatan dan retrieval rekam medis merupakan bagian dari implementasi sistem penomoran unit. Pasien baru dibuatkan rekam medis saat di layani di bagian pendaftaran, sedangkan untuk pasien lama diambilkan rekam medis dari bagian filing. Apabila rekam medis tidak ditemukan pada saat kunjungan ulang maka petugas menggunakan formulir rekam medis rawat jalan lanjutan dan formulir tersebut akan digabungkan setelah rekam medis ditemukan. Adanya regulasi dan sistem penyediaan rekam medis tersebut menunjukkan RSUD Panembahan Senopai Bantul telah mengimplemantasikan standar MIRM 13 ep 1-5. Namun masih terdapat kendala implementasi pada standar MIRM 13 ep 4.Kata kunci: penyediaan, penomoran, urutan, retrieval, rekam medis
Background: Motivation is an important factor that can affect employee performance. If the employee feel satisfied with their work, the employee will produce good performance, and vice versa. Based on the result of the preliminary study with the head of the medical record unit, it is known that they never get a reward if they work well, In addition there are still many officer who come late and performance of officers is still not paid attention. This condition resulted in work performed by medical recorders at Nur Hidayah Bantul hospital is not optimal, so it will affect work motivation. Objective: To determine the relationship between work motivation and the performance of medical recorder in the Nur Hidayah Bantul Hospital Method: This is a quantitative research with cross sectional design. The data collection technique used total sampling with a total respondent of 16 medical recorder. Results: From the results of the study, the results of work motivation showed that most medical recorder had sufficient work motivation (63%) and the performance of medical recorder mostly had sufficient performance (81%). From the results of the Spearman’s rho test on the relationship between work motivation and the performance of medical recorder in the Nur Hidayah Bantul hospital obtained r value 0.522 and p value 0.38 which means that there is a significant relationship between work motivation and performance. Conclusion: There is a relationship between work motivation and the performance of medical recorder in the Nur Hidayah Bantul hospital.
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