Analisis Faktor Penyebab Ketidakamanan dan Kerahasiaan Rekam Medis di Rumah Sakit : Literature Review

Zuhriyah, Ulfa Fatimatuz (2020) Analisis Faktor Penyebab Ketidakamanan dan Kerahasiaan Rekam Medis di Rumah Sakit : Literature Review. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Medical records are important records documenting data about past and current illnesses and treatments written by health professionals who have provided care. Medical records must be kept secure and confidential. In the hospital, there are conditions that indicate insecurity and unconfidentiality of medical records, namely there are damaged and missing medical records, leakage of medical information, and release of medical information without complete requirements. The purpose of this study is to determine the factors causing the insecurity and unconfidentiality of medical records in the hospital. The research method is a literature review. From the results of the literature search, it was found 16 literature that met the inclusion and exclusion criteria. The results of the review show that the implementation of medical record security in hospitals is not optimal. As many as 8 articles (61.53%) from 13 articles indicated there are missing medical record files that not available when needed. The implementation of confidentiality of medical records in hospitals is also not optimal. As many as 6 articles (37.5%) from 16 articles indicated there are medical records that could be accessed by unauthorized parties. Factors causing insecurity and unconfidentiality of medical records in hospitals are individual factors, namely the lack of ability of officers to maintain security and confidentiality of medical records and there are officers with high school education level; organizational factors include insufficient of facilities and infrastructure, hospitals do not have standard operating procedures, and lack of leadership roles in providing direction and supervision; Psychological factors include the officers' lack of discipline in complying Standard Operating Procedures and there is no punishment for rule violators.

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