Factors Affecting Medical Records Management in Karakah Health Center Padang

Abstract

Medical records are an administration system that starts from recording while the patient is receiving medical services, followed by handling medical record files which includes organizing storage and removing files from storage to serve requests/borrowing from patients or for other purposes. All health service facilities are required to maintain medical records, including community health centers (Puskesmas). Based on initial data collection observations, it was found that medical record management was still carried out manually, for the information system the government still used the BPJS system. The health center is still relatively new, so several problems are still found regarding the administration of medical records, one of which is numbering medical records, storage that is not yet ideal, unclear policies regarding standard operational procedures and a shortage of medical record officers. Currently the puskesmas only has one medical records officer who holds a D3 RM degree, the rest are assisted by officers who have high school/equivalent qualifications. This research was carried out from March to May 2023. The results of the research state that the storage of medical record files at the Parak Karakah Health Center is still not optimal and needs to be improved. Judging from the human resource elements which are still insufficient, the management of medical records has not been carried out well. The large number of files found that do not have folders is also a concern for the future. Storage carried out using a decentralized method is considered not optimal in community health centers because it creates separate medical record files. Ideally, storage in community health centers is carried out using a centralized system because it only accepts outpatients. Keywords: Medical record, Management, Health Center, Factors