Pengelolaan Rekam Medis di Instalasi Rekam Medis Rumah Sakit Universitas Sumatera Utara

Abstract

Medical records are a vital component of hospital services, serving as documentation of patient identity, medical history, procedures, and treatments provided. Effective and structured management is therefore essential. This study aims to examine the management of medical records at the Medical Records Unit of the University of North Sumatra Hospital. A qualitative case study approach was employed, with data collected through interviews, direct observation, and document review. One key informant directly involved in medical record management participated in the study. The findings reveal that medical record management still encounters significant challenges. Limited human resources and inadequate facilities and infrastructure hinder the process, which includes sorting, coding and indexing, storage, and reporting. Insufficient storage facilities, such as cabinets and shelving, often lead to misplaced, mixed, or lost files. The study suggests continuous training programs to enhance staff competencies, as well as improved provision of storage facilities and infrastructure to optimize the management of medical records.