Analisis Faktor Predisposing, Enabling, dan Reinforcing Terkait Terjadinya Duplikasi Penomoran Rekam Medis Rawat Jalan di RS Baladhika Husada Jember

Ayu Puspitasari, Dyah (2019) Analisis Faktor Predisposing, Enabling, dan Reinforcing Terkait Terjadinya Duplikasi Penomoran Rekam Medis Rawat Jalan di RS Baladhika Husada Jember. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

A good hospital is a hospital that is able to provide good service. One of the good services is the implementation of correct medical record management, where the management in question is including the initial numbering system of a series of services to patients. Based on the results of observation at Baladhika Husada Jember Hospital there are still double numbering of 40 document every month, which has an impact on the retrieval of patients's medical record files, and errors in actions due to the latest diagnosis or the last action listed on medical files not the last used on when patients get medical services. The purpose of the study was to analyze the factors causing duplication of medical record numbering. This type of research is qualitative by collecting data through interviews, observation, and documentation. The results showed that duplication of medical record numbering was lack of knowledge of outpatient registration officers about numbering systems, no SIMRS, less optimal SOP and absence of SOP socialization, officers attitude was indifferent if duplication of medical record numbering occurred, there was no reward, the peer support has not been optimum yet. The priority causes of the problems found using the CARL method are the SOP numbering is not detailed and there is no socialization (score 500). Suggestions that are given based on the main cause of problem are revising and socializing the SOP numbering. Another alternative solution is to provide training in numbering systems to registration officers, further education for high school graduates, and the provision of SIMRS.

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