Tinjauan Pelaksanaan Sistem Penyimpanan Berkas Rekam Medis Family Folder di Puskesmas Kutoarjo

YOGA NUR HIJRIANTO, Susilawati S.K.M., M.P.H

2018 | Tugas Akhir | D3 REKAM MEDIS SV

Latar Belakang: Sejak perubahannya dari sistem penyimpanan personal folder ke family folder, pelaksanaan penyimpanan family folder masih mengalami kendala dari segi stok formulir, perlengkapan penyimpanan, kebijakan yang ada, sumber daya manusia, dan standar isi dalam formulir yang belum sesuai standar rekam medis, serta rekam medis belum disimpan berdasar wilayah di rak penyimpanan. Tujuan: Mengetahui pelaksanaan sistem penyimpanan berkas rekam medis family folder di puskesmas kutoarjo. Metode : Penelitian deskriptif dengan pendekatan kualitatif. Rancangan penelitian menggunakan studi kasus. Teknik pengumpulan data melalui wawancara, observasi, dan studi dokumentasi. Hasil : Sistem penyimpanan rekam medis: tidak dilakukan pengecekan kelengkapan rekam medis, sistem penyimpanan sentralisasi, sistem penomoran unit numbering system, sistem penjajaran straight numerical filing. Peminjaman dan pengembalian rekam medis: tidak menggunakan tracer maupun buku ekspedisi peminjaman dan pengembalian, belum terdapat SK dan SOP pengendalian rekam medis. Sumber daya manusia pelaksana penyimpanan: petugas rekam medis belum sesuai standar. Kesesuaian item formulir rekam medis: terdapat item yang kurang sesuai standar pada formulir rekam medis gawat darurat. Perlengkapan penyimpanan: keterlambatan pengadaan map, kurangnya rak, tidak menggunakan tracer, pembatas dan petunjuk penyimpanan. Hambatan: hambatan utama dalam pelaksanaan sistem penyimpanan family folder adalah SDM yang belum sesuai standar. Kesimpulan : Pelaksanaan sistem penyimpanan rekam medis family folder di Puskesmas Kutoarjo masih belum begitu baik. Hambatan utama pelaksanaan sistem adalah SDM belum sesuai standar, sehingga perlu peningkatan kompetensi melalui pelatihan rekam medis.

Background: Since the change from personal folder storage system to the family folder storage system, the implementation of the family folder storage system is still experiencing difficulties, both in terms of stock form, storage equipment, existing policies, human resources, and content standards in forms that have not complied with the standard of medical record. Objective: To know the implementation of family folder storage system at Puskesmas Kutoarjo. Methods: Descriptive research with qualitative approach. The study design uses case studies. Technique of collecting data through interview, observation, and study documentation Results: Medical record storage system: not checking the completeness of medical records, storage used centralized storage system, unit numbering system, straight numerical filing system. Implementation of borrowing and return of medical records: not use tracer or lending and return expedition books, no medical record control SOP. Human resources implementing storage: medical record officers are not up to standard. Compliance of medical record form items: there are some items that are less standard on the emergency medical record form. Storage equipment: delays in procurement of folders, lack of shelves, not use tracers, delimiters and storage instructions. Obstacles: the main obstacles is the human resources that have not been up to standard. Conclusion : Implementation of medical record storage system family folder still not so good. The main obstacle to the implementation of the system is that human resources has not been up to standard, so it needs to increase competence through medical record training

Kata Kunci : family folder, sistem penyimpanan, sumber daya manusia