Analysis of Standard Operational Procedures implementation on medical records completion at Stella Maris Hospital in Makassar, Indonesia

Fadila, Rizki; Noor, Noor Bahry; Mangilep, Adellia U.A.; Irwandy,

doi:10.1016/j.enfcli.2019.07.023

Cited by 4 publications

(5 citation statements)

References 3 publications

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“…Setiap sarana pelayanan kesehatan memerlukan manajemen dalam mengelola rekam medis agar kegiatan rekam medis berjalan dengan baik sehingga dapat menghasilkan informasi yang lengkap dan akurat untuk menunjang kualitas pelayanan di sarana pelayanan kesehatan. Sarana pelayanan kesehatan wajib membuat Standar Operasional Prosedur (SOP) mengenai rekam medis agar seluruhkegiatan dapat dilakukan sesuai dengan kebijakan SOP yang telah dibuat (Rizki et al, 2020).…”

Section: Pendahuluanunclassified

Literatur Review Management Analysis of Medical Record Management System in Puskesmas

Kohar

2024

Radinka J. Health Sci

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The medical record management system at the community health center level is the same as the hospital medical record management system. This study aims to determine the management of the medical record system in health centers. This study is a literature review using methods of traditional review to seek, identify, evaluate, and interpret theoretical references relevant to the management of medical record systems in public health centers. The numbering system used in the health center is the Unit Numbering System, The medical record naming system uses a direct naming system, a centralized medical record document storage system at the health center, and a medical record document alignment system at the health center, namely a direct number alignment system and alignment system per region area. According to alphabetical order, assembly activities have not been carried out properly because there is no standard operating procedure for their implementation. The coding implementation at the community health centers did not use the ICD-10 book as a guideline for providing disease codes, the community health centers did not have a fixed retention schedule, so the retention and destruction of medical record documents at the community health centers had not been implemented. Conclusion: The numbering and naming system implemented at the community health centers is inappropriate, and the implementation of the medical record data processing system at the community health centers has not been optimal.

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Section: Pendahuluanunclassified

Literatur Review Management Analysis of Medical Record Management System in Puskesmas

Kohar

2024

Radinka J. Health Sci

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“…Priotitas pertama yaitu kualifikasi Pendidikan, jika rumah sakit tidak membenahi kualifikasi pendidikan staf yang bekerja di instalasi rekam medik akan menyebabkan pelayanan tidak optimal, hal ini dikarenakan oleh kurangnya pengetahuan karyawan yang tidak memenuhi syarat mengenai tugas perekam medis seperti yang ditemukan pada hasil penelitian dinyatakan bahwa salah satu faktor penyebab terhambatnya sistem pelayanan di instalasi rekam medis adalah kurangnya pengetahuan karyawan, karyawan yang tidak mengikuti perkuliahan perekam medis secara formal juga tidak dapat memiliki STR (Surat Tanda Registrasi) dan SIK (Surat Izin Kerja) dimana berarti mereka tidak paham kode etik profesi perekam medis. 20 Sebagaimana kita ketahui kode etik perekam medis menjunjung tinggi privasi dan keamanan isi dokumen rekam medik, kualitas pelayanan Kesehatan terutama rumah sakit juga dinilai dari bagaimana layanan Kesehatan dapat menjaga kerahasiaan rekam medis pasien. 21 Kedua yaitu membenahi beban kerja yang diberikan kepada staf di instalasi rekam medik RS Prikasih, dimana selama ini seluruh staf masih mengerjakan pekerjaan ganda yang tidak sesuai dengan uraian tugas masing-masing, penelitian yang dilakukan oleh Musriati, dkk menemukan bahwa beban kerja yang berlebih menyebabkan sistem pelayanan di instalasi rekam medik tidak berjalan sebagaimana mestinya.…”

Section: Pembahasanunclassified

“…22 Beban kerja yang berlebih juga dapat menyebabkan SOP (Standar Oeprasional Prosedur) yang ditetapkan tidak berjalan maksimal. 23 Selanjutnya, membenahi sarana dan prasarana pendukung pelaksanaan pelayanan rekam medis. Sarana dan prasarana yang lengkap dan memenuhi standar dapat menjamin privasi rekam medis, dengan sarana dan prasarana yang lengkap manajemen layanan Kesehatan di rumah sakit dapat mempersingkat waktu tunggu pasien dan keluarga.…”

Section: Pembahasanunclassified

Analisis Kebutuhan Kompetensi SDM Instalasi Rekam Medik dengan Metode Analytical Hierarchy Process

Rum,

Saud

2023

JIKM

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Berdasarkan survey pendahuluan ditemukan bahwa petugas di instalasi rekam medik jumlah dan kompetensinya masih kurang seimbang jika dibandingkan jumlah pengunjung rumah sakit, sehingga pelayanan menjadi kurang efektif dan efisien. Tujuan penelitian ini untuk mengetahui prioritas kebutuhan kompetensi SDM di instalasi rekam medis pada masa pandemi COVID-19 dan menyusun rencana strategi peningkatan kompetensi SDM. Penelitian ini merupakan penelitian kualitatif dengan pendekatan studi kasus yang di dalamnya peneliti menyelidiki secara cermat peristiwa dan aktivitas suatu kelompok di rumah sakit, dalam penelitian ini tipe desain penelitian yang digunakan adalah single-case (holistic), karena unit analisis yang digunakan hanya satu yaitu instalasi rekam medik. Hasil penelitian didapatkan urutan prioritas dari perhitungan AHP (Analytical Hierarchy Process) kebutuhan kompetensi sumber daya manusia di instalasi rekam medik prioritas pertama yaitu kualifikasi Pendidikan, dilanjutkan pengalaman kerja, pelatihan keahlian, beban kerja dan sarana prasarana. Ditemukan bahwa kualifikasi Pendidikan staf rekam medis belum sesuai, pengalaman kerja staf cukup, pelatihan keahlian staf cukup, beban kerja yang diberikan tidak sesuai, dan sarana prasarana pendukung belum sesuai.

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“…Completeness of medical record documents must be completed within 2x24 hours if there are still deficiencies in the document then it is called DMR (Delinquent Medical Record), [18] Quantitative analysis is the result of identifying the patient's social status, a correction note for writing errors with a one-time cross and the initials of the person responsible, ie authentication, the signature of the doctor responsible with the name and time, and the reporting must be in accordance with operational standards at the Ungaran general hospital. While the qualitative analysis includes a review of the completeness, recording, and consistency of the diagnosis, a review of actions, approval based on information, and a review of compensation risks.…”

Section: Quantitative and Qualitative Analysis Of 15 Inpatient Medical Record Documentsmentioning

confidence: 99%

Completeness of filling medical record documents on inpatient ward, Ungaran General Hospital-Semarang, Central Java -Indonesia

Wiji

Astuti

Isworo

2020

GSC Biol. and Pharm. Sci.

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Ungaran Hospital is a type C referral hospital in Semarang regency, therefore it must have excellent and good service, including services for patients and patient's regularity medical records. The mechanism for filling out medical record documents is often a barrier to services which results in a delayed return of medical record documents. This study aims to determine the effectiveness of filling medical record documents in 8 wards, in January -February 2020. The purpose of this study: This study aims to determine the incompleteness of filling medical record documents which result in delays in submitting medical record documents to the assembly unit. This research was conducted from February to March 2020, with the type of descriptive research that is interviews and observations of medical records officers. The results of the study were based on the calculation of 30 medical record documents consisting of 15 inpatient medical record documents and 15 outpatient medical record documents, the checklist table used to determine the completeness of filling medical record documents. Based on the analysis of medical record documents on hospitalization which includes a review of identification, reporting, authentication, and recording of 30 medical record documents studied there were 28 complete medical record documents and 2 incomplete medical records. It is necessary to provide guidance to doctors/nurses considering the importance of completeness of the contents of medical record documents in accordance with the conditions or needs of patients.

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Analysis of Standard Operational Procedures implementation on medical records completion at Stella Maris Hospital in Makassar, Indonesia

Cited by 4 publications

References 3 publications

Literatur Review Management Analysis of Medical Record Management System in Puskesmas

Literatur Review Management Analysis of Medical Record Management System in Puskesmas

Analisis Kebutuhan Kompetensi SDM Instalasi Rekam Medik dengan Metode Analytical Hierarchy Process

Completeness of filling medical record documents on inpatient ward, Ungaran General Hospital-Semarang, Central Java -Indonesia

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