Analisis Faktor Penyebab Terjadinya Duplikasi Penomoran Rekam Medis di Fasilitas Pelayanan Kesehatan: Literature Review

Annisa, Tamami Alifia (2022) Analisis Faktor Penyebab Terjadinya Duplikasi Penomoran Rekam Medis di Fasilitas Pelayanan Kesehatan: Literature Review. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Medical record files that have not been combined with the previous file will decide the information on services provided to patients which results in unstructured patient data, it is difficult for doctors to provide diagnosis and therapy to patients, this is related to the quality of service. The purpose of this study is to review the factors that cause duplication of medical record numbering based on the Man, Money, Method, Machine, and Materials factors. The research method used is a literature review. Selection of literature based on inclusion and exclusion criteria. The databases used are Google Scholar, Crossref, and Portal Garuda. The amount of literature found was 16 articles, consisting of 16 journals. The results obtained in this study are the man element due to lack of thoroughness and responsibility of the officers, the lack of officers with a medical record diploma/bachelor degree background, as well as the lack of training and seminars for officers, the money element due to limited funding sources for holding training and seminars for officers other than the head of the installation, as well as the increase in the budget due to the increased use of medical record supporting materials, the method element due to the implementation of the existing SOP (Standard Operational Procedure) that has not been carried out regularly, the machine element because some of them are already using a computerized system but some are constrained because the system still often experiences errors, and the material element is due to the availability of infrastructure but not being carried out properly and patients who still often do not bring KIB when they return for treatment. Suggestions that can be done to overcome this are by providing further education facilities to officers who have worked so that they have the appropriate competence in their fields, prepare special budgets, socialize SOPs for numbering medical records, carry out computer system maintenance on a regular basis, disseminate information to patients to always carry KIB , as well as enforce the existence of punishment and reward.

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