Evaluasi Pelaksanaan Penyimpanan Rekam Medis di Ruang Filing Klinik UNEJ Medical Center (UMC) Jember

Azizah, Sandi Nur (2023) Evaluasi Pelaksanaan Penyimpanan Rekam Medis di Ruang Filing Klinik UNEJ Medical Center (UMC) Jember. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

The storage of medical records is aimed at documenting and preserving medical records for future use in providing services to patients who may return to the healthcare facility. Observations made at UNEJ Medical Center Clinic in Jember indicate that not all medical records are stored in an organized manner some medical records are stacked. This condition can disrupt the medical records filing system, which should facilitate the retrieval and return of medical record files by staff. This research aims to evaluate the implementation of medical record storage in the filing room of UNEJ Medical Center (UMC) Clinic in Jember using a system evaluation approach and the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance). This research is qualitative in nature, and data collection techniques include interviews, observations, and documentation. The research subjects include two medical record staff, the general administration and personnel coordinator, and the medical support services coordinator. The results of the research show that medical record staff have a background in medical record education and knowledge about medical records. Some medical records have physical damage, and not every medical record is protected with a folder. Furthermore, there are still other staff members entering and exiting the medical record room. The implementation of medical record storage can be considered less than optimal and not in accordance with the applicable Standard Operating Procedures. This can be attributed to the inadequacy of the facilities and infrastructure available in the filing room. The suggestion from this research is to make improvements and additions to the available facilities and infrastructure to support more optimal medical record storage, thus enhancing the assessment process during future accreditation.

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