Analisis Faktor Penyebab Keterlambatan Pengembalian Rekam Medis Rawat Inap di Rumah Sakit Baladhika Husada Jember

Insani Dzakirah, Demiawan Rachmatta Putro Mudiono, Maya Weka Santi, Erna Selviyanti
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Abstract

The standard for returning outpatient medical records is 1 hour after providing polyclinic services and 1 x 24 hours after the patient is discharged. Delay in returning outpatient medical records occurs if it exceeds the predetermined standard limit. The implementation of medical records at Baladhika Husada Jember Hospital still has delays in returning inpatient medical records so that it has an impact on patient waiting time to get services, as well as the accumulation of files due to the procurement of new medical record documents for visiting patients because the previous medical records were not in the filing room. The purpose of this study was to analyze the factors causing delays in returning inpatient medical records. This type of research uses qualitative research, the subject is 1 head of medical record unit, 1 medical record officer, 3 nurses, 2 heads of inpatient rooms, the object of this research is inpatient medical records. The results found in this study are that the first priority has not been socialization related to SOP (Standard Operational Procedure) regarding the return of inpatient medical records so it is determined that efforts to hold routine SOP socialization, providing SOPs are posted in each inpatient room by involving all nurses and record officers related to medical record return activity.
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分析了延迟返回Baladhika Husada Jember医院住院记录的因素
门诊病历的归还标准为提供综合门诊服务后1小时,出院后1 × 24小时。超过预定标准限度的,延迟归还门诊病历。Baladhika Husada Jember医院在实施医疗记录方面仍然存在退还住院病人医疗记录方面的延误,因此对病人等待获得服务的时间产生了影响,并且由于以前的医疗记录不在档案室中,因此需要为来访的病人采购新的医疗记录文件,从而造成档案的积累。本研究的目的是分析造成住院病人病历延迟归还的因素。本研究采用定性研究,研究对象为1名病案单位负责人、1名病案员、3名护士、2名住院室负责人,研究对象为住院病案。本研究的结果发现,第一优先事项并不是与住院病历归还相关的SOP(标准操作程序)相关的社会化,因此确定要努力进行常规的SOP社会化,提供在每个病房张贴SOP,让所有与病历归还活动相关的护士和记录员参与。
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