TINJAUAN SALAH LETAK REKAM MEDIS RAWAT JALAN DI UPTD RSUD KOTA SALATIGA

ABSTRACTREVIEW OF OUTPATIENT MEDICAL RECORD MISPLACED OUTPATIENT MEDICAL RECORDS AT THE UPTD IN THE SALATIGA CITY HOSPITAL Paramita*), Elise Garmelia, S.K.M., S.Sos., M.Si**).Jurusan Rekam Medis dan Informasi Kesehatan, Politeknik Kesehatan Kemenkes SemarangPatient medical record data that is stored properly and correctly can improve health services at the hospital. The storage system for medical records in the UPTD of the Salatiga City Hospital uses a decentralized storage system, with its alignment using the final numerical alignment system (digit digit terminal). However, in the alignment in the UPTD of the Salatiga City Hospital, the medical records in the 2 final group numbers as the first digit still have some that have not been properly realized. The purpose of this study is to find out the location of outpatient medical record errors by recapitulating calculations from aspects of misfile, double numbers and the use of color codes to carry out the alignment of outpatient medical records. The type of research used is descriptive research with quantitative analysis of a review of misplaced outpatient medical records at the UPTD in the Salatiga City Hospital. The method of collecting data using observation with the Research Instrument is observation with the checklist method.Based on the recapitulation of the calculation of the number of medical record occurrences misplaced (misfile) in the alignment system obtained 26%, namely as many as 26 medical records and the number of double number events 16%, namely as many as 16 medical records out of a total of 100 medical records. To minimize the number of errors in storing medical records in the alignment system, one of them is to re-regulate the use of color codes. Based on the results of the research on the storage of outpatient medical records in the alignment system found 59 medical record documents affixed to the color code and 41 medical record documents that were not affixed to the color code from the number of documents studied 100 medical record documents. From the research results, there are still medical records that are not affixed to the color code even though the use of color codes is a means of minimizing the rate of misfile occurrenc