Tinjauan Pengelolaan Rekam Medis di Puskesmas Gamping II Sleman Yogyakarta

TALITHA RAHMA L, Dr. Nur Rokhman, S.Si., M.Kom.

2020 | Tugas Akhir | D3 REKAM MEDIS DAN INFORMASI KESEHATAN

Latar Belakang : pengelolaan rekam medis di Puskesmas Gamping II terdapat beberapa permasalahan seperti pelaksanaan pendaftaran manual, kegiatan filing oleh petugas cleaning service, supir ambulance, dan tata usaha, serta beberapa kegiatan pengelolaan belum terdapat SOP yang menyebabkan lambatnya proses pelayanan, dan dikhawatirkan adanya kebocoran informasi berkas rekam medis. Tujuan : Tujuan umum dari penelitian ini adalah memberi gambaran pengelolaan rekam medis di Puskesmas Gamping II Sleman Yogyakarta. Metode : Penelitian ini menggunakan penelitian deskriptif dengan pendekatan kualitatif dan rancangan penelitian studi kasus. Subjek penelitian adalah tiga petugas rekam medis dan delapan petugas BP Puskesmas Gamping II. Objek penelitian yaitu pengelolaan rekam medis. Teknik pengambilan data dengan teknik observasi, wawancara, dan studi dokumentasi. Uji keabsahan data dengan triangulasi. Hasil : Beberapa kegiatan pengelolaan rekam medis dilaksanakan tanpa SOP dan dilakukan oleh petugas selain rekam medis . Masih terdapat beberapa permasalahan pengelolaan rekam medis terkait alur berkas rekam medis, assembling, coding, indexing, penyimpanan, retensi, dan pelaporan berdasar 5M(man, materials, machines, methods, money). Petugas Puskesmas Gamping II melakukan berbagai upaya seperti meningkatkan tegangan genset, diberikannya izin akses terhadap petugas cleaning service, supir ambulance, dan tata usaha dengan syarat tertentu dan mengikuti kegiatan yang sudah dilakukan petugas sejak awal. Kesimpulan : Pengelolaan rekam medis masih tergolong belum baik dilihat dari beberapa permasalahan berdasar 5M. Diperlukan penyesuaian perbaikan kebijakan terkait SK Kepala Puskesmas dan SOP Pengelolaan rekam medis di Puskesmas Gamping II Sleman.

Background : There are several problems in managing medical records at the Puskesmas, which causes slow service processes, less than maximum service activities, and there is concern that there will be leakage of medical record file information Objective : The general objective of this study is to provide an overview of the management of medical records at the Gamping II Sleman Yogyakarta Health Center Methods : The research used descriptive research with a qualitative approach and case study research design. Research subject included three medical record officers and eight polyclinic officers at the Gamping II Health Center. Research objects included the management of medical records. Data collection techniques with observation techniques with observation techniques, interwiews, and study documentation. Test the validity of the data by triangulation. Result : Some medical record management activities are carried out without SOP and carried out by officers other than medical records. There are still some medical record management issues related to medical record file flow, assembling, coding, indexing, storage, retention, and reporting based on 5M (man, materials, machines, methods, money). Gamping II Health Center make various efforts to overcome these problems so that the activities in the management of medical records can still run smoothly. Conclusion : Management of medical records is still not good seen from several problems based on 5M. It is necessary to adjust policy improvements related to the decree of the Head of Health Center and standard operational procedures on the management of medical records at Gamping II Health Center

Kata Kunci : Tinjauan, Pengelolaan Rekam Medis, Puskesmas