Evaluasi Proses Pengelolaan Rekam Medis Pasien di Rumah Sakit Umum Dharma Yadnya

Abstract

Background: The process of managing medical records at Dharma Yadnya General Hospital is not in accordance with the work procedures and organization of health service facilities. This can be seen from incomplete medical records, doctor writing is not specific in diagnosis and human error which results in errors in taking medical records. Purpose: This study aim to evaluate the process of managing patient medical records at Dharma Yadnya General Hospital. Method: This research is descriptive qualitative using in-depth interviews. The sampling technique used purposive sampling method with a sample of 6 people. Results: Based on the analysis results, 5 themes were discussed, namely assembling, filling, coding, indexing, filling and retention activities. Overall, the management of patient medical records at Dharma Yadnya Hospital has not been able to run optimally, namely the filling of incomplete medical record documents, namely patient identity, diagnosis, medical resume, signature of the doctor in charge of the service and there are still errors in placing medical records (missfiles) so that the management of medical records takes a long time so that the assembling, coding, indexing, filling and retention processes are hampered. Conclusion: The management system of patient medical records at RSU Dharma Yadnya starting from assembling, coding, indexing, filling and retention have not been run optimally.