PENGELOLAAN BERKAS REKAM MEDIS INAKTIF DI RUMAH SAKIT JIWA Prof. Dr. SOEROJO MAGELANG

CAHYA HARDI LAKSONO, Dina Fitriana Rosyada, S.K.M., M.KL.

2021 | Tugas Akhir | D3 REKAM MEDIS DAN INFORMASI KESEHATAN

Latar Belakang : Seiring dengan pertambahan jenis pelayanan di RSJ Prof. Dr. Soerojo Magelang membuat bertambahnya berkas rekam medis. Penelitian ini difokuskan pada pengelolaan berkas rekam medis inaktif karena pada tahun ini pengelolaannya sedang berjalan. Tujuan : Mengetahui Pengelolaan Berkas Rekam Medis Inaktif di Rumah Sakit Jiwa Prof. Dr. Soerojo Magelang Metode : Jenis penelitian deskriptif kualitatif dan perancangan penelitian studi kasus. Subjek penelitian 2 petugas rekam medis, 1 petugas administrasi umum, dan 1 kepala rekam medis. Objek penelitian pengelolaan berkas rekam medis. Teknik pengumpulan data dengan wawancara, studi dokumentasi, dan observasi. Uji validitas data menggunkanan triangulasi sumber. Hasil : Penyusutan berkas rekam medis sudah ada SPO namun penyusutan belum terlaksana secara teratur. Penyimpanan berkas rekam medis inaktif berbeda tempat, terdapat ada petugas di bagian pengelolaan, sistem penyimpanan menggunakan TerminallDigitlFiling, terkait kebjikan penyimpanan menggunakan Permekes no.269 tahun 2008, namun belum ada alur dan SPO tentang penyimpanan berkas rekam medis inaktif. Masih terdapat kerusakan pada berkas rekam medis dan penataan berkas rekam medis inaktif belum sesuai standar. Kesimpulan : SPO penyusutan sudah ada, tetapi penyusutan berkas rekam medis belum dilakukan sesuai SPO . Penyimpanan berkas rekam medis inaktif sudah berbeda tempat, terdapat petugas dibagian pengelolaan, menggunakan sistem Terminal Digit Filing (TDF), kebijakan menggunakan Permenkes no.269 tahun 2008, tetapi belum ada SPO dan alur penyimpanan berkas rekam medis inaktif. Berkas rekam medis masih mengalami kerusakan dan penataan berkas belum sesuai standar.

Background of the study : Along with the increasing types of services at RSJ Prof. Dr. Soerojo Magelang made an additional of medical record files. This research is focused on managing inactive medical record files because the management is ongoing this year. Purpose : Analyzing the Management of Inactive Medical Record Files in Rumah Sakit Jiwa Prof. Dr. Soerojo Magelang. Methods : The type of descriptive qualitative research and designing research of case study. The subjects of the study were 2 medical record officers, 1 general administration officer, and 1 head of medical records. The object of the research is medical record file management. Data collecting method by interview, documentation study, and observation. The data validity test used source triangulation. Result : The shrinkage of medical record files already has SOP but the shrinkage has not been carried out regularly. The storage of inactive medical record files is from different places, there are officers in the management department, the storage system uses Terminal Digit Filing, related to the storage policy using Permekes no.269 of 2008, but there is no plot and SOP regarding to the storage of inactive medical record files. There is still damage to the medical record files and the arrangement of inactive medical record files was not carried to the standard. Conclusion : Standard Operating Procedure of shrinkage has already exists, but the shrinkage of medical record files has not been carried out according to SOP. The storage of inactive medical record files has different places, there are officers in the management division, using the Terminal Digit Filing system, the policy was used Permenkes no.269 of 2008, but there is no SOP and plot of inactive medical record file storage. The medical record file is still damaged and the file arrangement was not carried out to the standard.

Kata Kunci : inaktif, kerusakan, penyimpanan, penyusutan