PELAKSANAAN RETENSI DOKUMEN REKAM MEDIS AKTIF DAN IN AKTIF DI RSUD K.R.M.T WONGSONEGORO SEMARANG

Abstract

ABSTRACT

 

Based on the preliminary survey in the regional public hospital of K.R.M.T Wongsonegoro in Semarang, it was found that the document storage still used decentralized system. The Decree of Director of RSUD K.R.M.T Wongsonegoro Semarang stated that the retention period of medical record documents was based on the wards and certain cases or diseases. This research was aimed at knowing the description of the retention implementation procedures toward active and in active medical record documents in RSUD K.R.M.T Wongsonegoro Semarang. The research was descriptive using cross sectional approach. The research instruments were the guidelines of interview and observation, and a mobile phone as a recorder. The techniques of data collection were through observation and structured interview. The data were analyzed through collecting, editing, and then were analyzed descriptively. The result of the research shown that RSUD K.R.M.T Wongsonegoro Semarang had operational policy of active and in active medical record documents storage system. Those documents were transferred into the active medical record shelf for five years, while the in active medical record documents would be stored for two years. The two-year-in active documents, according to their usage, could be stored forever but the juxtaposition is not yet unresolved SPO . It could be concluded that RSUD K.R.M.T Wongsonegoro had had policy about the retention implementation system toward active and in active medical record documents. The sorting of the medical record documents on shelves active and assessment had been suitable with the SOP. It was suggested that the archive retention schedule should be made in the retention implementation, and the juxtaposition system had to be adjusted by the SOP of the hospital.

Keywords : Retention, Medical records active & In active

 

 

ABSTRAK

 

Berdasarkan survey pendahuluan di RSUD K.R.M.T Wongsonegoro Semarang menggunakan penyimpanan desentralisasi. Surat Keputusan Direkturr di RSUD K.R.M.T Wongsonegoro Semarang menyebutkan bahwa jangka waktu penyimpanan dokumen rekam medis sesuai dengan ruang perawatan dan kasus/penyakit tertentu. Tujuan penelitian untuk mengetahui gambaran pelaksanaan retensi dokumen rekam medis di RSUD K.R.M.T Wongsonegoro Semarang. Jenis penelitian deskriptif dengan pendekatan secara cross sectional. Instrumen penelitian berupa pedoman wawancara (Interview), handphone sebagai alat perekam, dan pedoman observasi dengan cara pengumpulan data observasi dan wawancara terstruktur. Pengolahan data yaitu pengumpulan (collecting), edit (editing), memaparkan (narasi) dengan analisis deskriptif. Hasil penelitian diketahui bahwa RSUD K.R.M.T Wongsonegoro mempunyai kebijakan penyelenggaraan sistem penyimpanan dokumen rekam medis aktif dan in aktif. Dokumen tersebut dipindahkan ke rak aktif disimpan selama 5 tahun. Dokumen rekam medis di rak in aktif disimpan selama 2 tahun. Setelah 2 tahun in aktif sesuai dengan kegunaan dokumen rekam medis tersebut seterusnya dapat disimpan seumur hidup tetapi penjajarannya belum sesuai dengan SPO. Simpulan bahwa RSUD K.R.M.T Wongsonegoro Semarang telah memiliki kebijakan tentang penyelenggaraan sistem penyimpanan dokumen rekam medis aktif dan in aktif. Pemilahah dokumen rekam medis di rak aktif dan in aktif telah sesuai dengan SPO tetapi belum dibuatkan JRA. Disarankan dalam pelaksanaan retensi dibuat JRA, dan sistem penjajaran harus disesuaikan dengan SPO rumah sakit.

Kata Kunci: Retensi, Rekam Medis Aktif dan In Aktif,