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Isnaini Qoriatul Fadhilah
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TINJAUAN FAKTOR - FAKTOR PENYEBAB TERJADINYA DUPLIKASI NOMOR REKAM MEDIS DI PUSKESMAS BAWANG II Sri Widiyanti; Isnaini Qoriatul Fadhilah
JOURNAL OF MEDICAL RECORDS AND HEALTH INFORMATION Vol 2 No 1 (2021): JOURNAL JOURNAL OF MEDICAL RECORDS AND HELATH INFORMATION
Publisher : Malang: Sekolah Tinggi Ilmu Administrasi Malang

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Abstract

Latar Belakang: Duplikasi yang terjadi di Puskesmas Bawang II sebanyak 8 berkas pada bulan Januari 2020, yang berdampak pada aspek legalitas berkas rekam medis terganggu apabila terjadi kasus hukum dan kesalahan dalam melakukan tindakan dikarenakan diagnosa terakhir atau tindakan terakhir yang tertera di berkas rekam medis bukan terakhir dipergunakan pada saat pasien mendapatkan pelayanan medis.Tujuan: Penelitian ini bertujuan untuk mengidentifikasi penyebab terjadinya duplikasi nomor rekam medis di Puskesmas Bawang II.Metode: Jenis penelitian adalah kualitatif dengan pengumpulan data wawancara, observasi, dan dokumentasi serta melalui pendekatan cross sectional, dimana pendekatan ini dilakukan dengan melihat kondisi pada saat pelaksanaan penelitian, yang dapat dilakukan sewaktu-waktu. Peneliti melakukan wawancara terhadap kepala instalasi rekam medis dan petugas pendaftaran, kemudian observasi dilakukan terhadap kegiatan pendaftaran dan proses kegiatan penomoran pasien.Hasil: Hasil penelitian yang didapatkan bahwa sistem penomoran yang digunakan di Puskesmas Bawang II adalah unit numbering system. Penyebab masalah adanya duplikasi nomor rekam medis meliputi faktor man, material, dan method, salah satunya yaitu pendidikan petugas yang belum sesuai kualifikasi D3 Rekam Medis.Kesimpulan: Sistem penomoran rekam medis di Puskesmas Bawang II menggunakan Sistem Penomoran Unit (Unit Numbering System) dengan jenis penomoran personal folder,dan menggunakan sistem penyimpanan SNF (Serial Number Filing) sistem yang berurut dari nomor yang terkecil.
PENERAPAN MANAJEMEN RISIKO DI UNIT KERJA RMIK: STUDI KASUS PADA TEMPAT PENDAFTARAN PASIEN RAWAT JALAN (TPPRJ) RUMAH SAKIT Zefan Adiputra Golo; Arief Azhari Ilyas; Isnaini Qoriatul Fadhilah; Sugiharto
JRMIK Vol 4 No 1 (2023): JOURNAL OF MEDICAL RECORDS AND HEALTH INFORMATION
Publisher : Malang: Sekolah Tinggi Ilmu Administrasi Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58535/jrmik.v4i1.49

Abstract

Background: TPPRJ as a leading unit that provides services to patients needs to minimize the risks and hazard that can be experienced by officers and patients. From a preliminary study at one of the local government hospitals in the Central Java region, it was found that at the outpatient registration point there was no Standar Procedur Operational (SPO) regarding risk management, so there was no standard set for risk control for officers and patients.Objective: The purpose of this study is to identify the application of risk management in the outpatient registration site (TPPRJ) of the hospital.Method: The type of research used in this study is qualitative descriptive with a case study design. The subjects of the study were 4 informants determined by purposive sampling techniques. Data collection through interviews and observationsResults: There are several risk factors in TPPRJ, namely from physical aspects (air temperature, lighting, radiation), biological aspects and ergonomic aspects. From the results of interviews and observations, it is known that the implementation of risk management in hospitals has been running, but it is still not optimal because it has not yet reached a comprehensive evaluation from the hospital's quality management.Conclusion: Risk management has been running but has not been maximized, because there is no SPO that specifically regulates risk management at TPPRJ. The risk management process that has been running is to identify risks, risk analysis and risk control.Keywords: Risk Management, RMIK Work Unit, TPPRJ
Co-Authors Arief Azhari Ilyas Sri Widiyanti Sugiharto Zefan Adiputra Golo