ANALISIS SISTEM PENGELOLAAN BERKAS REKAM MEDIS DI RUMAH SAKIT UMUM DAERAH ENCIK MARIYAM KABUPATEN LINGGA

Abstract

Rekam Medis adalah berkas yang berisikan catatan dan dokumententang identitas pasien, pemeriksaan, pengobatan, tindakanmedis lain pada sarana pelayanan kesehatan untuk rawat jalan,rawat inap baik dikelola pemerintah maupun swasta.Permasalahan yang ditemukan di RSUD Encik MariyamKabupaten Lingga sudah melaksanakan kegiatan rekam medis,namun dalam pengelolaan rekam medis belum berjalan optimal.Penelitian ini bertujuan untuk menganalisis penyebab belumterlaksananya pengelolaan rekam medis secara optimal di RSUDEncik Mariyam Kabupaten Lingga. Penelitian ini menggunakandesain penelitian deskriptif kualitatif. Penelitian ini dilaksanakanpada bulan September 2021 di RSUD Encik Mariyam KabupatenLingga, informan dalam penelitian ini berjumlah 4 orang yangterdiri dari 1 orang Direktur Rumah Sakit, 1 orang Kepala InstalasiRekam Medis, 1 orang CSO dan 1 orang pegawai bagianpenyimpanan. Pengumpulan data dengan wawancara secaramendalam dan observasi. Kesimpulannya masih kekuranganpetugas/SDM bagian rekam medis, Standar Operasional Prosedur(SOP) pengelolaan berkas rekam medis sudah ada tapi adakegiatan yang belum dilakukan sesuai SOP, Sarana/Prasaranayang mendukung dalam pengelolaan berkas rekam medis yangbelum memadai seperti belum ada KIUP, Fasilitas fisikpenyimpanan ketersediannya kurang, karena berkas selalubertambah-tambah, Pengelolaan rekam medis sering terhambatkarena gangguan jaringan untuk memproses SIMRS, dan dalampengembalian berkas kurang lengkap dan tidak tepat waktu. Sarandari penelitian perlu adanya peningkatan SDM, penyesuaian SOP,penambahan Sarana Prasarana dan fasilitas fisik penyimpananagar kegiatan pengelolaan berkas rekam medis berjalan optimal.   Medical Record is a file that contains records and documents regarding patient identity, examination, treatment, other medical actions at health service facilities for outpatient, inpatient, both managed by the government and the private sector. The problems found in the Encik Mariyam Hospital, Lingga Regency, have carried out medical record activities, but the management of medical records has not run optimally. This study aims to analyze the causes of the unimplemented optimal management of medical records in Encik Mariyam Hospital, Lingga Regency. This study used a qualitative descriptive research design. This research was carried out in September 2021 at the Encik Mariyam Hospital, Lingga Regency, the informants in this study were 4 people consisting of 1 Hospital Director, 1 Head of Medical Record Installation, 1 CSO and 1 storage employee. Data collection by in-depth interviews and observations. The conclusion is that there is still a shortage of officers/HR for the medical record section, Standard Operating Procedures (SOP) for managing medical record files already exist but there are activities that have not been carried out according to SOPs, Facilities/Infrastructure that support the management of medical record files are inadequate such as the absence of KIUP, Facilities physical storage availability is lacking, because files are always increasing, medical record management is often hampered due to network disturbances to process SIMRS, and file returns are incomplete and not on time. Suggestions from the research need to increase human resources, adjust SOPs, add infrastructure and physical storage facilities so that medical record file management activities run optimally.