Analisis Penyelenggaraan Rekam Medis Elektronik di RS Mata SMEC Medan

Abstract

The objective of the research is to find out the organization of electronic medical records at Sabang Merauke Eye Center (SMEC), Medan. The research employs descriptive qualitative method. The samples consist of seven informants, taken by using purposive sampling technique. The data are gathered by conducting observation, interview, and documentation and analyzed by using data reduction, data presentation, and conclusion drawing. The result of the research shows that the six indicators used in organizing medical records at SMEC Hospital Medan have been in accordance with Permenkes No. 24/2022 - 1) patient registration includes identification data and social data, 2) integrated distribution of electronic medical records among the computer/tabletpersonnel, 3) coding, reporting, and analyzing in processing electronic medical records, 4) code of illness input into INA-CBG application for cost reimbursement , 5) electronic medical records maintained in the cloud media, with access rights reserved and granted only to the PPA (Professional Care Giver), Medical Recorders, Claiming, and the hospital Manager, and 6) medical record standard committee has been made to ensure the quality of electronic medical records. Meanwhile, filling out clinical information is an improper indicator because some medical records are not filled out completely and clearly, and transferring the content of hospital electronic medical records has not been applied. In general, it could be said that organizing electronic medical records has been in accordance with the regulations.