TINJAUAN PELAKSANAAN ASSEMBLING DALAM PENGENDALIAN KELENGKAPAN REKAM MEDIS UNTUK PENINGKATAN MUTU PELAYANAN DI RSUD PONDOK AREN

Santi Lestari, Junaida Rahmi, Ima Rusdiana, Azzahra Berliana, Gama Bagus Kuntoadi

Abstract


Medical records are important documents that support the quality of health services, administration, and legal protection in hospitals. One of the important processes in medical record management is assembling, which is the process of collecting, arranging, and reviewing the completeness of medical record documents. This study aims to review the implementation of assembling in controlling the completeness of medical records to improve service quality at Pondok Aren Regional General Hospital.

This research used a quantitative descriptive design with purposive sampling. The sample consisted of 127 inpatient medical record files. Data were collected through observation sheets, documentation studies, and interviews with three medical record officers involved in the assembling process.

The results showed that the completeness of patient identity such as patient name, gender, and medical record number reached 100%. However, several components were still incomplete, including admission and discharge forms (79%) and medical resume (73%). In addition, the implementation of assembling had not been fully optimal due to limitations in human resources and the still manual medical record system.

The study concludes that the implementation of assembling in controlling the completeness of medical records at Pondok Aren Regional General Hospital still needs improvement. Hospitals are expected to conduct periodic evaluations and prepare for the transition to electronic medical record systems to improve the quality of medical record management.

Keywords


Assembling; Medical Record Completness; Medical Record Management; Quality Improvement

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References


Fitria Rakhmawati, dkk. (2023). Analisis Kebutuhan Perekam Medis Berdasarkan Beban Kerja di RS Aisyiyah Siti Fatimah.

Hakim, L., Ulfa, H. M., & Hamid, A. (2022). Faktor Yang Mempengaruhi Tidak Terlaksananya Assembling Di Rumah Sakit Pekanbaru Medical Center (PMC).

Noor Yulia, Erviana, E., Laela Indawati, & Muniroh, M. (2024). Literatur Review : Pengelolaan Assembling Rekam Medis Rawat Inap di Rumah Sakit. SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat, 3(1), 140–150. https://doi.org/10.55123/sehatmas.v3i1.3157

Putri, A., Lisnawati, & Hidayati, M. (2021). Analisis Ketidaklengkapan Pengisian Resume Medis Rawat Inap pada Kasus Covid-19 di RSUD Soreang 2021. http://sosains.greenvest.co.id

Rohmawati, A., Putri Supriadi, T. S., & Wahab, S. (2021). Tinjauan Pelaksanaan Assembling Dalam Pengendalian Ketidaklengkapan Dokumen Rekam Medis Rawat Inap di RSUD Soreang. Cerdika: Jurnal Ilmiah Indonesia, 1(9), 1079–1086. https://doi.org/10.36418/cerdika.v1i9.181

Salsiani, N. S. (2023). Analisis Kuantitatif Ketidak Lengkapan Pengisian Berkas Rekam Medis Pasien Di Puskesmas Wolio Kota Baubau.

Sari, R. O., & Widiyoko, A. (2024). Analisis Faktor Ketidaklengkapan Pada Resume Medis di RSUD Siti Fatimah Provinsi Sumatera Selatan. https://doi.org/e-ISSN:2986-6332

Ulfa, H. M. (2021). Pelaksanaan Assembling Rekam Medis di Rumah Sakit. Jurnal Rekam Medis Dan Informasi Kesehatan, 4(2), 57–62. https://doi.org/10.31983/jrmik.v4i2.6708

Yuliastuti, H. (2020). Tinjauan Pelaksanaan Assembling Dalam Pengendalian Ketidaklengkapan Berkas Rekam Medis di RSU Muslimat Ponorogo. In Jurnal Delima Harapan (Vol. 7).




DOI: https://doi.org/10.52031/erjermik.v5i1.1294

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