TINJAUAN DAMPAK TERJADINYA DUPLIKASI DOKUMEN REKAM MEDIS DI RUMAH SAKIT TK III Dr. R SOEHARSONO BANJARMASIN

  • Eka Rahma Ningsih Politeknik Unggulan Kalimantan
  • Amrina Rosada Politeknik Unggulan Kalimantan
  • Larasati Larasati Politeknik Unggulan Kalimantan
Keywords: Human Resources (HR), Standard Operating Procedures (SOP), Facilities and Infrastructure

Abstract

Medical records are files that contain notes and documents about the patient's identity, examination, treatment, actions of other services provided to patients at health facilities. One of them is giving a medical record number to the patient whose number is using a unit numbering system. This research was conducted to find out the activity of the numbering process of medical record documents at TK III Hospital Dr. R Soeharsono Banjarmasin. The purpose of this study was to determine the impact of duplication of medical record documents at TK III Hospital Dr. R Soeharsono Banjarmasin. The research method used is descriptive method with a qualitative approach. The results of this study to determine the impact of duplication of medical record documents which are caused by human resources who are not from D-III background medical recorders and health information, Standard Operating Procedure (SOP) numbering medical record documents have not been optimally implemented, facilities and infrastructure in the document the medical record for giving medical record numbers is not done fully using the unit numbering system, the tracer is not fully used, the Patient Main Index Card (KIUP) exists and is used, the Medical Identity Card (KIB) exists and is used, the register is only hospitalized while in outpatient has not used the register. The conclusion of this study is that human resources for the occurrence of duplication of medical record documents on registration officers did not perform optimally on the provision of medical record numbers to patients in accordance with standard operating procedures on numbering medical records, facilities and infrastructure in hospitals have been fulfilled only lacking application or the use of tracer and register books due to lack of human resources for the use of tracer, but in the register book the hours of service are limited to outpatient so that the application of the register book or its use has not been implemented so that it can cause duplication of patient medical record documents

Published
2020-04-30
How to Cite
Ningsih, E., Rosada, A., & Larasati, L. (2020). TINJAUAN DAMPAK TERJADINYA DUPLIKASI DOKUMEN REKAM MEDIS DI RUMAH SAKIT TK III Dr. R SOEHARSONO BANJARMASIN. Jurnal Kajian Ilmiah Kesehatan Dan Teknologi, 2(1), 45-50. Retrieved from http://jurnal.polanka.ac.id/index.php/JKIKT/article/view/34
Section
Articles