Analisis Pelaksanaan Pelepasan Informasi Rekam Medis dalam Menjamin Aspek Kerahasiaan Rekam Medis di Rumah Sakit : Literature Review

Ramadhanti, Alifia Tirta (2022) Analisis Pelaksanaan Pelepasan Informasi Rekam Medis dalam Menjamin Aspek Kerahasiaan Rekam Medis di Rumah Sakit : Literature Review. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Information in the medical record is confidential and can be disclosed by making a written request to the head of the health service facilities. Implementation in some hospitals still found non-compliance with procedures and incomplete requirements. The purpose of this study was to determine the implementation and problems in releasing medical record information based on Man, Facilities, and Method aspects. The research method uses literature review by searching and selecting articles on Google Scholar, Crossref, Portal Garuda, and Microsoft Academic which produces 24 selected articles. The results showed that in the Man aspect, the highest percentage of parties involved in releasing medical record information for insurance were medical record officers (84.21%), for education were students/educational agencies (100%), and for visum et repertum were the police (100%). In the Facilities aspect, the highest percentage of required documents that must be attached to the release of medical record information for insurance is a power of attorney (47.36%), for education is a research application letter (100%), and for visum et repertum is an official application letter or an official warrant from the police (100%). In the Method aspect, each hospital has a different flow, starting with the submission of requirements, approval of the leadership, processing of requests, and submission to applicants. Problems with the highest percentage include incomplete requirements (31.57%), officers do not understand the procedure (9.09%), and there is no Standard Operating Procedure (30.76%). Improvement efforts that can be made include increasing the competence and knowledge of officers through training, making x-banners regarding the flow and requirements in the implementation that are placed at the reception or hospital lobby, as well as reinforcing Standard Operating Procedures.

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