Pelaksanaan Manajemen Rekam Medis dan Sistem Informasi Kesehatan di RS X Wonogiri
DOI:
https://doi.org/10.32585/jmiak.v5i2.2902Keywords:
medical record management, Health information system, SIRS,Abstract
ABSTRACT
In accordance with Law No.44 of 2009 concerning Hospitals in article 25, it is explained that each Hospital is required to record and report on all hospital implementation activities in the form of a Hospital Information System. The unit that is given the responsibility of managing statistics is the Medical Record section, namely by collecting data, processing data, and presenting data into information.
The implementation of medical record management at X Wonogiri Hospital for the implementation of retention/depreciation and destruction has been carried out. However, in the implementation of depreciation, it still needs attention because it has not been specifically scheduled, and for the space / place where inactive Medical Record documents are stored, it still needs improvement because the place is not spacious and Medical Record documents are not neatly arranged. For Types of Medical Record services at X Wonogiri Hospital has various forms. This form of Medical Record service includes paper-based Medical Record services. Medical Record manual paper-based document is a medical record that contains administrative and medical sheets that are processed in the system and stored manually. Medical Record Services that are processed into information and management in a computerized manner that runs on one system automatically in the Medical Record work unit. Hospital X uses a Management Information System, namely Pilar Hospital which has been integrated with Virtual Claim (VClaim) to facilitate the service of BPJS patients.
Keyword : medical record management, Health information system, SIRS, MIK
ABSTRAK
Sesuai dengan Undang – Undang No.44 Tahun 2009 tentang Rumah Sakit pada pasal 25 dijelaskam bahwa setiap Rumah Sakit wajib melakukan pencatatan dan pelaporan tentang semua kegiatan penyelenggaraan Rumah Sakit dalam bentuk Sistem Informasi Rumah Sakit. Unit yang diberi tanggungjawab mengelola statistik adalah bagian Rekam Medis yaitu dengan melakukan pengumpulan data, mengolah data, dan menyajikan data menjadi suatu informasi.
Implementasi manajemen rekam medis di Rumah Sakit X Wonogiri untuk pelaksanaan retensi /penyusutan dan pemusnahan sudah pernah dilakukan. Tetapi dalam pelaksanaan penyusutan masih perlu perhatian karena belum terjadwal khusus, dan untuk ruang/tempat penyimpanan dokumen Rekam Medis inaktif masih memerlukan perbaikan karena tempatnya yang kurang luas dan dokumen Rekam Medis yang belum tertata rapi. Untuk Jenis pelayanan Rekam Medis di Rumah Sakit X Wonogiri memiliki berbagai bentuk. Bentuk pelayanan Rekam Medis ini meliputi pelayanan Rekam Medis berbasis kertas. Rekam Medis manual paper based document adalah rekam medis yang berisi lembar administrasi dan medis yang diolah di tata dan di simpan secara manual. Pelayanan Rekam Medis yang di olah menjadi informasi dan pengelolaannya secara komputerisasi yang berjalan pada satu system secara otomatis di unit kerja Rekam Medis. Rumah Sakit X menggunakan Sistem Informasi Manajemen yaitu Pilar Hospital yang sudah terintegrasi dengan Virtual Claim (VClaim) sehingga memudahkan dalam pelayanan pasien BPJS.
Keyword : manajemen rekam medis, system informasi Kesehatan, SIRS, MIK
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