Analisis Pengelolaan Rekam Medis Rawat Jalan di Puskesmas Tempeh Kabupaten Lumajang

Salsabilla, Dianisa Ufairoh Nota (2023) Analisis Pengelolaan Rekam Medis Rawat Jalan di Puskesmas Tempeh Kabupaten Lumajang. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

The management of outpatient medical records at the Tempeh Primary Health Center still has several problems with the highest percentage in July, August, and September 2022 reaching 1.41% on the issues of filling in incomplete medical record. The aim of this study was to analyze the management of outpatient medical records at the Tempeh Primary Health Center based on motivation, opportunity, and ability factors.. This research used qualitative with in-depth interview data collection techniques, observation, documentation, and brainstorming. The subjects of this study were three medical record officers, three outpatient poly doctors, and the head of the primary health center. The results in this study were motivation factors, consisting of rewards and punishments that have been fulfilled and carried out well. The opportunity factors were the unavailability of SOPs at several management stages, the lack of human resources, insufficient time to manage outpatient medical records, and inadequate equipment such as storage racks, storage rooms, and expedition books. The ability factor was the knowledge of officers regarding the system used in the management of outpatient medical records was sufficient, though not all officers have an educational background in medical records, and the staff has never attended training regarding the management of outpatient medical records. The improvement efforts set to overcome these problems were making SOPs that are not yet available, transferring employees deemed competent from other units to the medical records department, optimizing working hours, expanding rooms and adding storage shelves, making expedition books, and providing training to medical record officers related to the management of outpatient medical records.

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