Evaluasi Pelaksanaan Penyimpanan Berkas Rekam Medis di RSUD Kota Yogyakarta

RAFIDA ELLI SAFITRY, Dina Fitriana Rosyada SKM., M.KL

2019 | Tugas Akhir | D3 REKAM MEDIS DAN INFORMASI KESEHATAN

Latar Belakang:RSUD Kota Yogyakarta menggunakan sistem penyimpanan secara sentralisasi, sedangkan sistem penjajarannya Terminal Digit Filing. Masalah yang masih terjadi adalah missfille, menumpuknya rekam medis inaktif di ruang penyimpanan aktif dan petugas sering kejatuhan berkas rekam medis ketika ingin mengambil dari rak penyimpanan. Permalasahan ini cukup menghambat pekerjaan petugas filing. Tujuan:Mengevaluasi pelaksanaan penyimpanan berkas rekam medis di RSUD Kota Yogyakarta. Metode:Jenis penelitian deskriptif dengan pendekatan kualitatif, rancangan penelitian fenomenologis. Subjek penelitian yaitu 2 petugas filing, 1 koordinator pengolahan data, 1 kepala instalasi rekam medis. Objek penelitian yaitu pelaksanaan penyimpanan rekam medis. Hasil:Landasan pelaksanaan yaitu SOP dan kebijakan. Penjajaran menggunakan TDF dan penyimpanan sentralisasi. Penggunaan kode warna pada dua digit angka terakhir nomor rm. Penyatuan berkas rm sementara dan baru untuk kesinambungan riwayat pasien Hambatan : jumlah rak penyimpanan kurang (material), pengoperasian komputer lambat (machine) dan jumlah SDM kurang (man). Permasalahan : duplikasi rm, missfile, keluhan dari tenaga kesehatan. Kesimpulan:Pelaksanaan penyimpanan berkas rekam medis sudah sesuai dengan SOP dan kebijakan. Hambatan terjadi dari segi man, material, machine. Sebaiknya kepala instalasi rekam medis mengajukan pemindahan unit filing ke lantai 1 kepada Direktur RSUD Kota Yogyakarta supaya satu lantai dengan poliklinik, sebaiknya pihak instalasi rekam medis mengadakan penambahan jumlah rak penyimpanan (roll o�pack) supaya berkas rekam medis dapat tersimpan dengan rapi di rak penyimpanan, sebaiknya pihak instalasi rekam medis melakukan rekrutmen pegawai/karyawan baru khusus untuk melakukan kegiatan retensi dan sebaiknya fasilitas komputer yang tersedia di unit filing dilakukan kegiatan maintenance secara berkala supaya dalam proses pengoperasiannya tidak lambat. Kata kunci:Evaluasi, Penyimpanan, Rekam Medis

Background :Yogyakarta City Hospital uses a centralized storage system, while the alignment system is Digit Filing Terminal. The problem that still occurs is missfille, accumulating active medical records in the active storage room and officers often dropping medical record files when they want to retrieve from the storage rack. These problem is enough to hamper the work of filing officers. Objective :To evaluate the implementation of storing medical record in Yogyakarta City Hospital. Methods :The type of research was descriptive research using a qualitative approach with phenomenological research design. Research subjects were 2 filing officers, a data processing coordinator, a head of medical record installation. The Research object was the implementation of medical record documents filing. Results :The implementation platform is SOP and policy. Alignment using TDF and centralized storage.Using the color code on the last two digits of the medical record number.Unification of temporary and new medical record for continuity of patient history. Barriers: the number of shelves is lacking (material), the operation of the computer is slow (machine) and the number of human resources is lacking (man). Problems: duplicating medical record, missfile, complaints from health workers. Conclusion :The storage of medical recordis in accordance with the SOP and policy. Obstacles occur in terms of man, material, machine. We recommend that the medical record installation head submit the filing unit to the 1st floor to the Director of Yogyakarta City Hospital so that one floor with the polyclinic, the medical records installation should add a roll of storage so that the medical record file can be stored neatly on the storage rack , it is better for the medical record installation to recruit new employees / employees specifically to carry out retention activities and the computer facilities available in the filing unit should be carried out maintenance activities regularly so that the operation process is not slow. Keywords :Evaluation, Filing, Medical Record

Kata Kunci : Evaluasi, Penyimpanan, Rekam Medis