分析苏加省UPT Puskesmas镇活动性医疗记录保存分析

Novi Indriyani Gunawan, Meita Nurseha, Mei Hidayati
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引用次数: 3

摘要

医疗记录保留是将医疗记录文件从一个活跃的存储室转移到一个不活跃的存储室的活动。根据UPT Puskesmas Sukarasa的初步调查,Puskesmas在2018年和2019年两次保留门诊病历文件。但是保留没有按照SOP来做。本研究的目的是确定Puskesmas Sukarasa UPT门诊病历文件保留的实施情况。这种类型的研究是描述性的回顾性方法。本研究采用观察法、访谈法和检查表法。本研究的目的是在UPT Puskesmas Sukarasa实施主动到非主动门诊病历保留。研究对象为负责病历的人员和负责门诊病历保存的登记人员。据了解,UPT Puskesmas Sukarasa已经有关于病历保存的SOP,但由于缺乏专门的保存人员和病历文件堆积在活跃的存储货架上,SOP一直没有实施。保留的文件是2016-2018年的文件,不查看最后治疗日期,而是根据医疗记录文件中的年号。然后,该文件立即移动到非活动存储机架。可以得出结论,UPT Puskesmas Sukarasa保留的实施不符合SOP。最好是按照SOP进行保留,并安排专人负责,这样就不会有病历档案的堆积。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Analisis Retensi Rekam Medis Rawat Jalan Aktif ke Inaktif di UPT Puskesmas Sukarasa
Medical record retention is an activity of transferring medical record documents from an active storage room to an inactive storage room. Based on a preliminary survey at UPT Puskesmas Sukarasa, it is known that the puskesmas has retained outpatient medical record files 2 times in 2018 and 2019. But the retention is not done according to the SOP. The purpose of the study was to determine the implementation of outpatient medical record file retention at UPT Puskesmas Sukarasa. This type of research is descriptive with a retrospective approach. The research instrument was carried out by observation, interviews and checklist forms. The object of the research is the implementation of active to inactive outpatient medical record retention at UPT Puskesmas Sukarasa. The research subjects are the officer in charge of medical records and the person in charge of registration who performs retention of outpatient medical records.It is also known that the UPT Puskesmas Sukarasa already has an SOP on retention of medical records, but the SOP has not been implemented due to the lack of special staff for retention and the accumulation of medical record files on active storage shelves. Files that are retained are files for 2016-2018 without looking at the last date of treatment but based on the year number in the medical record file. Then the file is immediately moved to the inactive storage rack. It can be concluded that the implementation of retention at UPT Puskesmas Sukarasa is not in accordance with the SOP.  It would be better if the retention is carried out according to the SOP with special and scheduled officers so that there is no accumulation of medical record files.
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