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PEMBERDAYAAN PETUGAS KESEHATAN TERKAIT PELAKSANAAN SISTEM PENYIMPANAN BERKAS REKAM MEDIS PASIEN Rea Ariyanti; Nita Dwi Nur Aini; Moh Maulana
SELAPARANG: Jurnal Pengabdian Masyarakat Berkemajuan Vol 7, No 3 (2023): September
Publisher : Universitas Muhammadiyah Mataram

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31764/jpmb.v7i3.16372

Abstract

ABSTRAKKlinik Moderna merupakan satu diantara klinik rawat inap pratama yang terdapat di Kabupaten malang yang menyelenggarakan pelayanan kesehatan secara perorangan, dimana rata-rata kunjungan pasien di klinik moderna berkisar 50 pasien per hari. Setiap fasilitas pelayanan kesehatan termasuk klinik wajib menyelenggarakan rekam medis. Salah satu kegiatan yang dilaksanakan dalam unit rekam medis adalah pengelolaan sistem penyimpanan berkas rekam medis. Belum terlaksananya sistem penyimpanan rekam medis di klinik Moderna yang sesuai SOP yang telah ditetapkan menyebabkan masih banyaknya berkas rekam medis yang tertumpuk di ruang penyimpanan yang berakibat pada terjadinya kerusakan fisik pada berkas rekam medis seperti map yang terlipat, robek, dan lain sebagainya. Selain itu, penyediaan berkas rekam medis juga akan menjadi lebih lama karena petugas harus mencari berkas rekam medis terlebih dahulu akibat rekam medis tidak disimpan secara baik di ruang penyimpanan rekam medis. Kegiatan pengabdian ini bertujuan untuk memberikan edukasi kepada petugas kesehatan terkait pentingnya pengelolaan sistem penyimpanan dan retensi berkas rekam medis sesuai dengan SOP yang berlaku. Kegiatan ini dilaksanakan sebanyak 3 kali dengan metode sosialisasi dan diskusi interaktif mengenai pelaksanaan sistem penyimpanan rekam medis yang dilakukan kepada petugas kesehatan. Dari hasil evaluasi, diketahui bahwa pengetahuan petugas kesehatan antara sebelum dan sesudah diberikan sosialisasi meningkat sebesar 70%, dimana sebelum diberikan edukasi, rerata nilai pretest sebesar 56.00 dan setelah diberikan edukasi rerata nilai postest menjadi 95.00. Kegiatan ini perlu dilakukan sebagai upaya meningkatkan kemampuan petugas kesehatan dalam melakukan identifikasi penyebab tidak terlaksananya sistem penyimpanan sesuai dengan SOP yang telah ditetapkan. Kata kunci: klinik; rekam medis; sistem penyimpanan ABSTRACTThe Moderna Clinic is one of the primary inpatient clinics in Malang Regency which provides individual health services, where the average patient visit at the Moderna clinic is around 50 patients per day. Every health care facility, including clinics, is required to maintain medical records. One of the activities carried out in the medical record unit is the management of the medical record file storage system. The medical record storage system at the Moderna clinic has not been implemented according to the SOP that has been set, causing many medical record files to pile up in the storage room which results in physical damage to medical record files such as folded, torn folders, and so on. In addition, the provision of medical record files will also take longer because officers must first search for medical record files due to medical records not being stored properly in the medical record storage room. This service activity aims to provide education to health workers regarding the importance of managing the medical record file storage and retention system in accordance with applicable SOPs. This activity was carried out 3 times with the socialization method and interactive discussion regarding the implementation of the medical record storage system for health workers. From the evaluation results, it is known that the knowledge of health workers between before and after being given socialization increased by 70%, where before being given education, the average pretest score was 56.00 and after being given education the average posttest score was 95.00. This activity needs to be carried out as an effort to improve the ability of health workers to identify the causes of not implementing the storage system in accordance with predetermined SOPs. Keywords: clinics; medical records; filling
Evaluasi Sistem Penyimpanan Berkas Rekam Medis di Klinik X Poncokusumo Kabupaten Malang Rea Ariyanti; Moh Maulana
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 1 (2023): December
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i1.4050

Abstract

Storage of medical record files is a key to successful management of a service. Storage is very important to see the patient's medical history and repeat visits, therefore the method of storing medical record files must be properly managed. Therefore, it is necessary to evaluate the storage system so that recommendations for improvements can be found regarding the storage of medical record files. This study aims to evaluate the medical record storage system at the X Poncokusumo Clinic, Malang. This study used a qualitative research design which was carried out at the X Poncokusumo Clinic, Malang with a total sample of 4 people which was carried out from March to July 2023. Data collection used interview and observation techniques. Presentation of data is done in a narrative form. The results of the study show that in the aspect of the objective (context) the storage system has not been achieved due to inadequate infrastructure (input), causing the activity (process) of storing medical record files to be not optimal. As for the results (product) of activities in the filling unit or storage system, it shows that there was a missfile incident and there was physical damage to the patient's medical record file.
Edukasi petugas rekam medis terkait penyusunan Standar Operasional Prosedur (SOP) sistem retensi berkas rekam medis Rea Ariyanti; Nita Dwi Nur Aini; Moh Maulana
SELAPARANG: Jurnal Pengabdian Masyarakat Berkemajuan Vol 8, No 1 (2024): March
Publisher : Universitas Muhammadiyah Mataram

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31764/jpmb.v8i1.21150

Abstract

AbstrakGuna menjalankan pelayanan kesehatan yang optimal maka diperlukan dukungan oleh unit-unit yang terkait didalamnya, salah satunya adalah unit rekam medis. Seiring dengan berjalannya waktu, berkas rekam medis pasien akan mengalami peningkatan dari tahun ke tahun, sehingga perlu diperhatikan terkait sistem filling dan sistem retensi berkas rekam medis. Retensi berkas rekam medis merupakan salah satu cara penting untuk mengatasi masalah penumpukan berkas yang tidak memiliki nilai guna lagi guna memberikan kapasitas serta pemeliharaan yang lebih baik baik bagi berkas yang memiliki nilai guna. Klinik X merupakan salah satu klinik yang ada di kabupaten Malang. Rata-rata kunjungan pasien di klinik X Poncokusumo Malang berkisar 50 pasien per hari, dimana hingga saat ini belum pernah dilakukan retensi berkas rekam medis, sehingga banyak rekam medis yang tertumpuk yang berakibat pada terjadinya kerusakan fisik pada berkas rekam medis seperti map terlipat, robek, dan lain sebagainya. Adanya penumpukan berkas rekam medis ini disebabkan karena sampai dengan saat ini belum pernah dilaksanakan retensi berkas rekam medis akibat dari belum adanya SOP terkait sistem filling dan retensi berkas rekam medis. Kegiatan PkM ini bertujuan untuk memberikan edukasi kepada tenaga kesehatan dalam penyusunan SOP  agar pelaksanaan sistem penyimpanan rekam medis dapat terlaksana dengan baik. Kegiatan ini dilaksanakan sebanyak 3 kali dengan metode sosialisasi dan diskusi interaktif mengenai penyusunan SOP sistem filling dan retensi berkas rekam medis. Dari hasil evaluasi, diketahui bahwa, terdapat peningkatan pengetahuan sebear 23% yang dilihat berdasarkan rerata nilai pretest petugas sebelum diberikan edukasi sebesar 65.00 dan setelah diberikan edukasi rerata nilai postest menjadi 80.00. Hasil PkM ini menunjukkan bahwa petugas kesehatan memiliki peningkatan pengetahuan terkait penyusunan SOP terkait sistem filling dan retensi berkas rekam medis. Kata kunci: edukasi; filling; retensi; SOP Abstract In order to provide optimal health services, support is needed from the units involved, one of which is the medical records unit. As time goes by, patient medical record files will increase from year to year, so it is necessary to pay attention to the filling system and retention system for medical record files. Retention of medical record files is one important way to overcome the problem of accumulating files that no longer have use value in order to provide better capacity and maintenance for files that have use value. Clinic X is one of the clinics in Malang district. The average patient visit at the X Poncokusumo Malang clinic is around 50 patients per day, where until now there has never been any retention of medical record files, so that many medical records are piled up which results in physical damage to medical record files such as folders folded, torn, and so forth. This accumulation of medical record files is due to the fact that up to now there has never been any retention of medical record files as a result of the absence of SOPs related to the system for filling and retention of medical record files. This PkM activity aims to provide education to health workers in preparing SOPs so that the implementation of the medical record storage system can be carried out well. This activity was carried out 3 times using socialization methods and interactive discussions regarding the preparation of SOPs for filling and retention systems for medical record files. From the evaluation results, it is known that there was an increase in knowledge of 23% which was seen based on the average pretest score of officers before being given education of 65.00 and after being given education the average posttest score was 80.00. The results of this PkM show that health workers have increased knowledge regarding the preparation of SOPs related to the filling and retention system for medical record files. Keywords: education; filling; retention; SOP