EVALUASI MUTU REKAM MEDIS DI RUMAH SAKIT DAERAH KOTA TIDORE KEPULAUAN

Background: Health services to the patients who come for a treatment can not be handled only one person. Therefore, it is needed a means of communication as a source of patient�s information stored sistematically. Medical record is one of information and comunication sources needed in the way of medical services and administrative activities at the hospital. However, the management of medical record has so far been constrained by the low quality of medical records. Several studies revealed incompleteness of medical record documents, the doctor�s writing which is hard to read and the management is impressed potluck. As well, in Kota Tidore Kepulauan regional public hospital where the managment of medical record is facing many obstacles such as lack of doctor awareness in filling medical records and lack of attention of management to the development of the skills of medical record clercks in the management of medical record. Research Method: This research is a descriptive qualitative research with a case study design. The research subjects were doctors, medical record unit clerks, nurse, midwives, head of development affairs and the director of the hospital. Data was retrieved by means of observation, medical record document checks, FGD and in depth interviews to research subjects. Research Result: The complacleteness of medical records in Kota Tidore Kepulauan Regional Public Hospital is still lacking (24, 93%). Data recorded is not accurate, retrieval of medical records is not on time, absence of SOP of medical record charging, complexity format of medical records, minimum of organizing in the unit of medical records, absence of storage procedure, destruction and confidentiality in medical record unit and ineffectiveness of coaching funtion and supervision from the management of Kota Tidore Kepulauan Regional Public Hospital. Conclusion: The quality of medical records in Kota Tidore Kepulauan Regional Public Hospital is still low and experiencing various obstacles including the limitation of medical record charging time, unavailbility of SOP used as a standar of medical records, complexity of medical record format, minimum of organizing efforts, storage, destruction and confidentiality of medical records, also there is no guidance efforts and suppervision from management