Analisis Pengolahan Rekam Medis Pasien Rawat Jalan pada Rumah Sakit Umum Sufina Aziz Medan

Abstract

The objective of this research is to determine the processing of medical records of outpatient at Sufina Aziz General Hospital Medan. This research is carried out at Sufina Aziz General Hospital Medan which is located at Jl. Karya Baru No. 1, Helvetia tim., Medan Helvetia Subdistrict, city of Medan, North Sumatra. The research uses a descriptive method with a qualitative approach. The data sources of this research are primary and secondary data. The research informants are determined by a purposive sampling with total of three people. The data are collected by means of observation, interviews, and documentation, sources triangulation, technique triangulation, time triangulation. The research results indicate that the processing of medical record data for outpatient at Sufina Aziz General Hospital Medan is as follows: First, in the arrangement of, medical records (assembling): the officer examines each medical record file, arranged according to the order of the form number and type of form. Second, coding uses ICD 9 and ICD 10. Third, the process of indexing: the officer records the patient’s identity, medical record number, and the diagnosis are filled in the patient’s main index card. Fourth, hospital reporting is made, namely internal reports and external reports. Fifth, medical record correspondence activities: make a letter regarding the patient’s medical record. Sixth, in the process of analyzing medical records at the hospital: the staff conducts analysis, notifies medical, records are returned to the treatment room. Seventh, medical record storage system uses a decentralized system. Eighth, retrieval of outpatient medical records that takes about 10-12 minutes. Ninth, depreciation of medical records and destruction at Sufina Aziz General Hospital Medan has been carried out once every 5 years, guided by the JRA at the Hospital and the destruction of medical records is carried out by burning or shredding. So it can be said that the processing of medical records for outpatient at Sufina Aziz General Hospital Medan, as a whole, is in accordance with the Department of Health, however, there are discrepancies in the process of medical records retrieval.