Analisis Pengelolaan Rekam Medis Rawat Inap Puskesmas Langga Payung Kabupaten Labuhan Batu Selatan

Abstract

The research aims ta find 0111 the management of inpatient medical record management i11 Langga Public Health Center of Labuhan Batu Selatan Regency. The descriptive research is conducted using qualitative method and the research informants aredetermined using purposive sampling technique. Three informants are selected and data are gathered through observation, Interview, and documentation. The result indicates that the medical records done by the medical staff includes patient data, number or medical record, BPJS registration number and type of membership. date and lime, phy.,ical examination, patient medical history, diagnosis, theraphy or tream,ent, secondary examination pl,an and other types of services. The medical records are managed using family folder system which are kept far 5 years on the shelves using terminal digit filling system. The disposal of medical records is conducted once eve,y five ta ten years without using any records of retention schedule as a guideline. In addition, the confidentiality of the medical records has not yet secured since the medico/ records are stored in the some room as the roam far patient registration.