Analisis Ketidakamanan dan Ketidakrahasiaan Rekam Medis di RSU Ananda Purwokerto

Mahfudhoh, Hasna Wildan (2024) Analisis Ketidakamanan dan Ketidakrahasiaan Rekam Medis di RSU Ananda Purwokerto. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

The safety of the medical record is the protection of medical record documents physically while the confidentiality of medical record is the restriction on the disclosure of patient’s personal information. The percentage of non-confidentiality can be seen from the high number of misfile cases due to the substantial number of unauthorized accesses as a result non-medical records officers frequently walked in the medical records room and borrowed documents without any permission reached by 71%, while medical recorders only reached by 42%. From the issue of medical records insecurity, it was still found the corrupted documents and misfile reached by 5,4 % in one year. The study objective focuses on analyzing insecurity and non-confidentiality of medical records based on 5 M theory (man, money, method, machine, money) by finding out the nucleus of issue using fishbone by undertaking the improvement of brainstorming. The nature of this study is qualitative with technique of data collection in detail, observation and documentation. The results represents that there is incompatibility education background for the man factor, the calculation has not been supported in money factor, even the officers do not have good understanding the content of SOP (Standard Operating Procedure) and the socialization of SOP has not been implemented in method factor. Moreover, closed circuit television and smart lockdoor in the supply room have not been used in machine factor. In addition, there is no checklist sheet for the return of out-patient medical records in material factor. These matters can be resolved by practicing once every 6 months for all medical record officers, making equipment submission to support the safety and the confidentiality of medical records as well as making checklist sheet for the return of medical records which is borrowed by out-patient.

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