Analisis Faktor Penyebab Terjadinya Duplikasi Nomor Rekam Medis Di RSUD Ibnu Sina Gresik

Khairunnisa, Gustri (2025) Analisis Faktor Penyebab Terjadinya Duplikasi Nomor Rekam Medis Di RSUD Ibnu Sina Gresik. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Medical record number duplication refers to a situation where a patient has multiple medical record numbers or when a single medical record number is shared by multiple patients. A preliminary study found that in the Monthly Outpatient Report from December 2023 to May 2024 at RSUD Ibnu Sina Gresik, 0.44% of cases involved medical record number duplication. Duplication causes inconsistency in the medical records of patients who have previously received treatment. This study aims to analyze the factors that cause medical record number duplication at RSUD Ibnu Sina Gresik. This research is qualitative, with subjects including one head of the medical records unit, three registration officers, and one IT officer. Data collection methods included interviews, observations, and documentation. The findings show that the individual competence factor is a major cause of duplication, as there has been no training related to medical record numbering, and staff are not careful in verifying the identity of patients who have previously received treatment. From the organizational support perspective, duplication occurs due to system errors in EHOS/SIMRS when searching and checking patient data, and there is no warning feature when duplication happens. From the management support perspective, while coordination exists, there is no dedicated team to handle medical record number duplication issues. The researcher recommends improvements, including enhancing the accuracy of registration officers when entering patient identity data. IT staff should add a warning feature to alert users when entering duplicate data, to minimize the risk of duplication. Registration officers should carefully re-check patient identities, and regular performance evaluations should be conducted

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