| dc.description.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. | en_US |
