Implementasi Manajemen Pengelolaan Sistem Rekam Medis Di Puskesmas Payung Sekaki Pekanbaru

Abstract

The medical record management system at the community health center (puskesmas) level is essentially the same as hospital medical record management. Mismanagement of medical records that does not follow procedures and guidelines can result in the loss of information in medical records. At Payung Sekaki Community Health Center, medical record management is still done manually, starting from registration services, searching for medical record documents, recording medical records, to storing medical record documents, with occurrences of duplicate medical record numbers. The method used in this research is descriptive, with three informants: the Head of Medical Records and two medical record staff. Data collection techniques include observation and interviews, with data sources consisting of primary and secondary data, data processing using triangulation techniques, and descriptive data analysis using qualitative methods. The results of this study show that the health center has human resources (HR) with a background in Diploma Three Medical Records, although not all staff have a medical records background. The health center continues to strive to improve the quality of medical records HR to ensure that medical record management at the health center keeps up with current developments in both quality and quantity. Policies for medical record management at the health center have been established in accordance with standards, but there are still staff who do not comply with the established standards, such as in the return of medical records. Available facilities include storage racks (cabinets), tables, chairs, medical record forms and folders, and a computer for patient registration, as well as writing tools. Additionally, the narrow space makes it difficult to retrieve medical records. The health center has not yet implemented a tracer/outguide system, and some medical record numbers are stored in boxes. Control of medical records, including the storage, return, and borrowing systems, still faces challenges. For example, the control system for record files has not optimally used the expedition book and tracer