Pengembalian Dokumen Rekam Medis Pasien Rawat Inap di Rumah Sakit: Literature Review

Handayani, Sari (2021) Pengembalian Dokumen Rekam Medis Pasien Rawat Inap di Rumah Sakit: Literature Review. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Based on medical record administration and health information guidelines, the inpatient medical record documents are returned to the medical record unit within 2x24 hours. However, the delays in returning inpatient medical record documents in the hospital are still common. It causes obstructed some medical record unit activity such as assembling, coding, data processing, insurance claim, medical information report, and patient service. The purpose of this study was to analyze the delays in returning inpatient medical record document factors in the hospital. The study used the literature review method to 16 articles that contain 11 journals and 5 theses, which were searched through Google Scholar, GARUDA, Rama Repository, and E-Library Politeknik Negeri Jember. The result of the research showed from 16 analyzed articles, the delays in returning inpatient medical record document caused by the lacks of doctor’s discipline in filing medical record document completely, there is no reward and punishment for obedient officers, lack of the standard operational procedure socialization in returning inpatient medical record document for the nurses and doctors, the distance between inpatient and medical record unit is too far, there are no facilities for helping in returning of medical record document activity in medical record unit such as trolley. The suggestion that could be given is, they need to conduct socialization of the standard operational procedure in returning inpatient medical record document at the hospital regularly. So that, the nurses and doctors is always pay attention to the specified time in returning of inpatient medical record document.

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