Analysis of Medical Record Management Process in Wahidin Sudirohusodo General Hospital

Authors : Andi Harnita; Amran Razak; Muhammad Asdar

Volume/Issue : Volume 5 - 2020, Issue 6 - June

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The role of the medical record is very important in the management of hospital services. medical record quality indicators are included in one of the hospital accreditation assessment standards. Therefore, this study aims to determine the Process of Organizing Medical Records in General Hospital. Wahidin Sudirohusodo. The study design uses a qualitative descriptive approach with exploratory methods. This research was conducted at Wahidin Sudirohusodo General Hospital in 2020. There were 7 informants in this study. Data analysis with an interactive model consists of three stages of data reduction, data presentation, concluding. Based on research results. In the process of registering medical records involved in this process, namely administrative or admission officers who are also part of the medical record unit, and nurses, the implementation of filling patient medical records is still found many obstacles, from disciplinary factors, knowledge, awareness, time and motivation of doctors and nurses are the main obstacle in filling out the medical record. The medical record management at WahidinSudirohuso Hospital has been proceeding from assembling, coding, indexing, but there are still obstacles encountered, namely the lack of officers in the process of quantitative and qualitative analysis of medical record files. HR in the medical record installation is inadequate, SOPs and channels are in place, the policy refers to Permenkes No. 269 of 2008, facilities and infrastructure were inadequate.

Keywords : component; Input; Process; Output; Operation system; Medical record.


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30 - June - 2023

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