IMPLEMENTASI PENYELENGGARAAN ASSEMBLING SESUAI DENGAN SOMR (SOURCE ORIENTED MEDICAL RECORD) DALAM MENUNJANG REKAM MEDIS YANG EFEKTIF DAN EFISIEN DI RUMAH SAKIT IBU DAN ANAK X PEKANBARU TAHUN 2023

Abstract

Assembling paper-based medical record services that are processed, organized and stored manually or based on Computerized Patient Records (CPR) is managed through an integrated information system. The method for simplifying the assembling process is using SOMR (Source Oriented Medical Record) which is sorted based on the date of visit. X Pekanbaru mother and child hospital has implemented assembling in services but needs improvements in accordance with Minister of Health Decree Number 129 of 2008 concerning Minimum Hospital Service Standards. The results of the performance report evaluation show that medical record documents must be assembled outpatient and inpatient if the patient makes a return visit to the doctor, it is easy to find the patient's previous history. The method used in this research was qualitative, with 3 informants, namely the Head of Medical Records and the medical records officer. Data collection techniques include observation and interviews. Data sources are primary and secondary, data processing using triangulation techniques, and descriptive data analysis techniques using qualitative methods. The results of the research are that the number of medical record personnel who have a Diploma Three in Medical Records background are still working to improve the quality of medical record human resources so that assembly is carried out in accordance with SOMR to support effective and efficient medical records the job description in carrying out the assembling work function has not been carried out properly, officers carry out assembling work and other work such as (activities of retrieving medical record files, printing patient identification, etc). Facilities and infrastructure available include a medical record work room, a filling room (availability of storage shelves, tables, chairs, forms and medical record folders), an integrated computer system for registering patients equipped with an internet network connection, stationery, air conditioning and lighting. enough (lights). Controlling medical records, including the system for storing, returning and borrowing medical records, still found problems such as not maximizing the use of assembling expedition books and delays in returning medical record files to the medical records room.