Analisis Pengolahan Rekam Medis Rawat Inap di Klinik Pratama Kesuma Bangsa Sei Piring Kabupaten Asahan

Abstract

This research aims to find out the management of inpatient medical records at Kesuma Bangsa Pratama Clinic, Sei Piring, Asahan Regency. This research is condicted at Kesuma Bangsa Pratama Clinic, Sei Piring, Asahan Regency, which is located at J. Lintas Sumatera, Desa Rahuning II, Rahuning Subdistrict, Asahan Regency, North Sumatra. Descriptive method is employed in this research and data are obtained from primary and secondary data sources, 3 people are determined as research informants, consisting of the head of the clinic, and 2 staffs of medical records. Data obtained are analysed using data reduction, data presentation, and conclusion drawing to analyze relevant and meaningful data. Data are collected xing observation, interviews, and documentation as well as source triangulation technique triangulation, time triangulation, The results describe the management of inpatient medical records at Kesuma Bangia Pratama Clinic, Sei Piring, Asahan Regency. The flow of medical record management is conducted until the assembling stage, starting from receiving medical record documents, then copying them in writing into the expedition book and placing them in a box. Coding is only found on the storage shelves. The indexing process is conducted by showing ID card or BPJS card which are then be recorded into the ledger. Internal report is the only report made, consisting of reports of incoming patients, discharged patients, deceased patients, childbirths and patients treated Correspondence is conducted out by making referral letters, letters for treatment and letters for pallent discharge. The analysis is carried out by rechecking to see if there are lacomplete medical records. The storage of medical record is conducted using a centralized system, with a storage period of 5 years. To retrieve the medical records the patient is required to show their ID card or BPJS card to the medical record officer, then the officer search for medical records on the storage rack. The depreciation of medical records in conducted when the age of medical records has reached 3 years old. Then, the medical records are destroyed by shredding burning