ANALISIS PELAKSANAAN REKAM MEDIS DI RUMAH SAKIT IBU DAN ANAK (RSIA ) WIDIYANTI

Abstract

ABSTRACT

Background : Medical record is one of the most important pillars that can not be considered trivial in a hospital, with the development of medical science

Common Purpose : To find in-depth information about the implementation of medical records at the hospital Widiyanti Palembang

Research Method : Qualitative research design with data collection techniques are conducted in triangulation, The data analysis is inductive, and the results of the study are emphasized more at the meaning than the generalization.

The Research Results : the Implementation of medical records have been running but there is no medical record organization, the implementation of medical record activities done by rolling. Human Resources (HR) medical records should be placed specifically in the medical record along with clear tasks. Method of organizing medical record has been run although the result is not optimal, because Standard Operational Procedure
(SOP) that made not socialized. Facilities and infrastructure that support the implementation of the medical record is good, marked by the existence of a special records archive medical records. Facilities and infrastructure such as chairs, desks, computers, patient registration books and outpatient registration and inpatient services are available, do not have budget funds for medical record implementation, especially by sending medical recruiter for training

Conclusion : Implementation of medical records have been running but not optimal.