Analisis Sistem Pengelolaan Rekam Medis di Puskesmas Sri Padang Tebing Tinggi

To create good medical record services, it is necessary to manage good medical records in accordance with procedures and guidelines from Permenkes No. 24 of 2022 concerning Medical Records. However, based on an initial survey research, the Sri Padang Health Center did not use electronic medical records, and according to information from the Tebing Tinggi Health Office’s Data Recording and Reporting Unit, the Sri Padang Health Center was still experiencing delays in data entry and annual data reporting. This study aims to find out how the medical record management system is at the Sri Padang Tebing Tinggi Health Center. The type of qualitative research is descriptive. The research informantsconsisted of 3 main informants: namely the head of medical records, the executor of medical records, and general practitioners, the triangulation informant was 1 person, namely the head of the puskesmas. Informant selection technique with purposive sampling. Data collection techniques with interviews and observation. Research instruments with interview guidelines. The results showed that the medical record management system at the Sri Padang Health Center had not fully used the electronic medical record system, the distribution, coding, indexing, storage, and retention activities were still not optimal, especially the placement of officers, and there were obstacles in the management process, namely inadequate storage support facilities, lack of accuracy of doctors and nurses in filling out medical records, there is no skill development for substitute medical record officers and the confidentiality of medical-records is not maintained because there is no special medical record officer.Untuk menciptakan pelayanan rekam medis yang baik, maka diperlukan pengelolaan rekam medis yang baik sesuai dengan prosedur dan pedoman dari Permenkes No. 24 Tahun 2022 tentang Rekam Medis. Namun berdasarkan survey awal penelitian Puskesmas Sri Padang belum menggunakan rekam medis elektronik, serta menurut informasi dari Unit bagian Pencatatan dan Pelaporan Data Dinas Kesehatan Tebing Tinggi, Puskesmas Sri Padang masih mengalami keterlambatan dalam mengentry data dan pelaporan data tahunan. Penelitian ini bertujuan untuk mengetahui bagaimana sistem pengelolaan rekam medis di Puskesmas Sri Padang Tebing Tinggi. Jenis penelitian kualitatif bersifat deskriptif. Informan penelitian terdiri dari 3 orang informan utama yaitu kepala rekam medis, pelaksana rekam medis dan dokter umum, informan triangulasi 1 orang yaitu kepala puskesmas. Teknik pemilihan informan dengan purposive sampling. Teknik pengumpulan data dengan wawancara dan observasi. Instrumen penelitian dengan pedoman wawancara. Hasil penelitian menunjukkan bahwa sistem pengelolaan rekam medis di Puskesmas Sri Padang belum sepenuhnya menggunakan sistem rekam medis elektronik, kegiatan pendistribusian, pengkodean, indeksing, penyimpanan dan retensi masih belum optimal terutama penempatan petugas, terdapat kendala dalam proses pengelolaannya yaitu belum memadainya sarana penunjang penyimpanan, kurangnya ketelitian dokter dan perawat dalam pengisian rekam medis, tidak adanya pengembangan keterampilan bagi petugas rekam medis pengganti serta tidak terjaganya kerahasiaan rekam medis sebab belum adanya petugas khusus rekam medis