Analisis Faktor Penyebab Keterlambatan Pengembalian Berkas Rekam Medis Rawat Inap Di Rumah Sakit: Literature Review

Setiyaningsih, Rini (2021) Analisis Faktor Penyebab Keterlambatan Pengembalian Berkas Rekam Medis Rawat Inap Di Rumah Sakit: Literature Review. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Based on the 2006 Yanmed Director General, the medical record standard for discharged patients is a maximum of 2x24 hours after the patient is declared home. In Erlindai's research (2019), it was found that the inaccuracy of only the file time, the number of medical record files was 63 or 72.41% and the number of files on time was 24 or 27.59%. Inaccuracy in the handling of medical files causes inaccuracies in the processing of medical record data which will affect policy making, management decisions, and delivery of information to patients. The purpose of this study was to analyze the factors causing the delay in inpatient medical files at the hospital. The research method used is a literature review through a search by reading various sources of articles according to the research topic. Articles that review as many as 20 articles that meet the criteria for articles and research topics. The results of the study showed that the factors causing the delay in medical files at the hospital were caused by the indiscipline of doctors and nurses in filling out inpatient medical record files with the largest percentage, namely 75%. Efforts that can be made are conducting socialization related to the importance of medical record training and the role of medical personnel in completing medical records, conducting socialization of file SOPs and involving officers in seminars and. Adding file facilities, providing budget for adding new employees, creating jobdes, implementing rewards, punishments, monitoring and evaluation. improve and coordinate communication between co-workers, make policies to disseminate form filling and carry out medical committees. Create an information system related to inpatient medical record files. Keyword: delay, return, medical record, literature review

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