EVALUASI PELAKSANAAN SISTEM LOKASI PENYIMPANAN DESENTRALISASI REKAM MEDIS DI RS SYUHADA HAJI BLITAR

KARTIKA SARI WANODYA, Dr. dr. Wahyudi Istiono, M.Kes

2018 | Tugas Akhir | D3 REKAM MEDIS SV

Latar Belakang: RS Syuhada Haji Blitar menggunakan sistem lokasi penyimpanan rekam medis secara desentralisasi. Terdapat empat tempat penyimpanan rekam medis yaitu di TPP IGD dan rawat inap, TPP poliklinik umum, TPP klinik kandungan, serta di unit rekam medis. Sistem penjajaran yang digunakan ialah SNF dan secara kronologis. Dampak yang sementara terlihat ialah missfile, duplikasi dan komplain. Tujuan: Mengevaluasi pelaksanaan sistem penyimpanan desentralisasi di RS Syuhada Haji Blitar. Metode Penelitian:Jenis penelitian deskriptif dengan pendekatan kualitatif, rancangan penelitian fenomologis. Subjek penelitian yaitu 11 petugas rekam medis,2 perawat,1 asisten perawat. Objek penelitian yaitu sistem penyimpanan berkas. Hasil: Faktor yang mendasari adalah kebijakan dan alokasi dana. Penjajaran menggunakan SNF dan penyimpanan kronologis. Adanya penyatuan berkas untuk kesinambungan. Perawat dan asisten perawat melakukan penerimaan dan penyimpanan. Pelaporan secara manual dan komputerisasi. terdapat rencana pengubahan ke penyimpanan sentralisasi.Hambatan: filing dikerjakan semua orang, penumpukan berkas yang belum diolah, tidak ada trolly. Dampak : missfile karena tracer tidak digunakan, duplikasi akibat salah pencarian di sistem dan akibat missfile, lama pencarian berkas rawat inap, berkas pasien lebih dari satu, terjadi pemeriksaan dari awal kembali Kesimpulan:Terdapat kebijakan tertulis terhadap pelaksanaan sesuai teori, cara penyimpanan dan penjajaran sesuai teori namun tidak sesuai kebijakan dan SOP. Perawat dan asisten perawat melakukan penyimpanan, penerimaan tidak sesuai dengan undang-undang. Pelaporan secara manual dan komputerisasi sesuai dengan undang-undang. Adanya rencana ke sentralisasi agar penyimpanan sistematis sesuai dengan teori. Terdapat kebijakan penggunaan tracer namun tidak dilaksanakan, waktu pencarian berkas rawat inap tidak sesuai undang-undang. Berkas lebih dari satu dan pemeriksaan dari awal tidak sesuai dengan teori agar berkesinambungan.

Background: Syuhada Haji Blitar Hospital uses decentralized medical records localitation storing system. There are four medical record storages. They are Admission Department in Emergency Department and inpatient room, general polyclinic, gynecology clinic, and medical record unit. The alignment system that is used is SNF and chronological-based alignment. There are temporary impacts that are founded. They are misfile, duplication and complaint. Objective: To evaluate the implementation of the decentralized storing system in the Syuhada Haji Blitar Hospital. Methode: The type of research is descriptive research using a qualitative approach with phenomenological research design. Research subjects were 11 medical record officers, two nurses, and a nurse assistant. The research object is the file storage system. Result: Main factors of decentralized storing are policy and fund allocation. SNF and chronological storage alignment are used. The existence of file unification for continuity. Nurses and nursing assistants do acceptance and storage. The report is done manually and computerized and a plan to convert to centralized storage Obstacles: Filing is done by everyone, there are accumulations of unprocessed files, paper map usage, numbers are not jutting out, and there are no trolleys. Impact: misfiling due to lack of usage of tracer, duplication due to wrong searching in the system and misfiling, length of hours of inpatient file search, a patient file is more than one, checking from start again. Conclusion: There is a written policy toward implementation which is accordant with the theory, so are the storage and the alignment, but they are not accordant with the policy and SOP. Nurses and nursing assistants do the storing; the acceptance is not accordant to law. The existence of a plan to change into centralized systematic storage is accordant with the theory. There is a tracer usage policy but is not implemented, the search time for inpatient files is not accordant to the law. There is more than one file, and checks from the beginning are incompatible with the theory in order to have a continuation.

Kata Kunci : Evaluasi, Desentralisasi, Rekam medis