Analisis Proses Pengambilan Kembali (Retrieval) Rekam Medis di Rumah Sakit Umum Daerah (RSUD) dr. RM Pratomo Bagansiapiapi

Abstract

The objective of this study is to investigate the process of medical record retrieval at Dr. RM Pratomo Bagansiapiapi Regional General Hospital. This descriptive study employs a qualitative approach. Data collection methods include observation, interviews, and documentation. The gathered data comprise primary data, collected directly from respondents, and secondary data, sourced from literature reviews including books, journals, and other relevant materials. Techniques for data analysis encompass data reduction, data display, and data verification. The results showed that the medical record retrieval process at Dr. RM Pratomo Bagansiapiapi Regional General Hospital encompasses several key components: 1) the release of medical records; 2) exit guidance utilizing tools such as loan cards, tracers, and outguides; 3) color coding for the folders or covers of medical records; 4) the adoption of storage policies and procedures, characterized by a terminal digit system and centralized storage principles; 5) the distribution of medical records; and 6) strategic planning for the incineration of inactive medical records. It is found that the retrieval process is conducted manually following requests from the registration to the medical record department based on specific medical record numbers, after which the files are dispatched to the respective clinics. The medical records department has effectively implemented strategies concerning storage policies, record distribution, and the management of inactive records. Nonetheless, aspects such as medical record release, exit guidance, and the color coding system for folders and covers are currently not in practice.