TINJAUAN PELAKSANAAN RETENSI DOKUMEN REKAM MEDIS AKTIF KE IN AKTIF DI RUANG FILING RSUD DR.MOEWARDI

Abstract

ABSTRACT

 

 

Based on the preliminary survey at the Hospital Dr. Moewardi have implemented retention as much as two times. Hospital Dr. Moewardi perform medical record document retention outpatient and inpatient every month as many as 12,000 documents, from 2012 until now has not been completed. The purpose of this study was to determine the implementation of active medical record document retention in all active in filing space Hospital. Dr. Moewardi. This research is a descriptive, cross sectional approach. The research instrument is a structured interview guidelines and observation guidelines by collecting data through observation and structured interviews. Data have been obtained will be recycled with processing techniques following collection (collecting), editing (editing), and present data with data analysis using descriptive. The survey results revealed that the preparatory document retention of medical records in the active active to have appointed a special officer with SK Head Installation Medical Record. Implementation of retention since 2012 until now has not been completed because every day to reach 400-500 diretensi documents. Filing clerk who implement retention only 2 people. Filing space there are two rooms belonging to 1 with active filing space and storage space there are 72 medical record documents in the space in the active section. As for the alignment Terminal Digit Filing (TDF) requires 100 section. The inference that the preparation stage medical record document retention active in active in the SOP to be reviewed with regard to determinations that should be the last year of patients treated replaced by the date of the last patient’s treatment. Suggested preparation phase retention time should be on creating the list for removal form the active medical records to document in an active and need to add specialized staff retention and supply section.

 

Keywords : Retention, DRM is active and in active

Bibliography : 11 (2006-2015)

 

 

ABSTRAK

 

 

Berdasarkan survei pendahuluan di RSUD Dr. Moewardi telah melaksanakan retensi sebanyak 2 kali. RSUD Dr. Moewardi melakukan retensi dokumen rekam medis rawat jalan dan rawat inap setiap bulan sebanyak 12.000 dokumen, dari tahun 2012 sampai sekarang belum selesai. Tujuan penelitian ini adalah mengetahui pelaksanaan retensi dokumen rekam medis aktif ke in aktif di ruang filing RSUD. Dr. Moewardi. Jenis penelitian ini adalah deskriptif, dengan pendeka- tan cross sectional. Instrumen penelitian berupa pedoman wawancara terstruktur dan pedoman observasi dengan cara pengumpulan data menggunakan observasi dan wawancara terstruktur. Data yang telah didapat akan diolah kembali dengan teknik pengolahan sebagai berikut pengumpulan (collecting), edit (editing),dan menyajikan data dengan analisis data menggunakan deskriptif. Hasil penelitian diketahui bahwa persiapan retensi dokumen rekam medis aktif ke in aktif telah menunjuk petugas khusus dengan SK Kepala Instalasi Rekam Medis. Pelaksanaan retensi sejak tahun 2012 sam- pai saat ini belum selesai dikarenakan setiap harinya mencapai 400 – 500 dokumen yang diretensi. Petugas filing yang melaksanakan retensi hanya 2 orang. Ruang filing terdapat 2 ruang yang tergabung menjadi 1 dengan ruang filing aktif dan ruang penyimpanan dokumen rekam medis ada 72 section di ruang in aktif. Sedangkan untuk penjajaran Terminal Digit Filing (TDF) membutuhkan 100 section. Simpulan bahwa tahap persiapan retensi dokumen rekam medis aktif ke

 

in aktif di SOP perlu dikaji kembali terkait dengan penentuan yang seharusnya tahun terakhir pasien berobat diganti den- gan tanggal terakhir pasien berobat.Disarankan Tahap persiapan saat retensi sebaiknya di buatkan daftar formulir pemin- dahan dokumen rekam medis aktif ke in aktif, dan perlu menambahkan petugas khusus retensi dan penyediaan section.

 

Kata kunci : Retensi, DRM aktif dan in aktif

Kepustakaan : 11 (2006-2015)