SENTRALISASI PENGELOLAAN REKAM MEDIS DI PUSKESMAS BINAAN MIJEN KOTA SEMARANG DALAM MENYONGSONG SJSN DI INDONESIA

Abstract

Research Program in Mijen Primary Health Center Semarang was based on a variety of problems found in the field, which is related to the management of medical records that has not been stored in a centralized, thus does not guarantee the continuity of a patient’s medical information. While the continuity of medical information be required to ensure the safety of medical services for the patients. Even the MRD storage systems applied in inpatient filing system was not purely decentralized filing because a patient’s MRD stored per treatment period, not combined in 1 (one) inpatient MRD folder. In addition, storage management of inactive and timeless MRD were not orderly. Inactive and timeless MRD are stacked in the warehouse without documentation and certain procedures. Solutions offered are medical records management training for 10 (ten) employees who worked at the TPPRJ, TPPRI, outpatient filing and inpatient filing of Mijen Primary Health Center. Furthermore, the design and socialization of fixed procedures (SOPs) in the management of medical records TPPRJ, TPPRI, outpatient filing and inpatient filing, implementation of retention and inactive MRD value, as well as SOPs on implementation of inactive and timeless MRD storage. In addition, the brief assistance in revamping medical record management system in Mijen Primary Health Center. Research pogramme was carried out for 8 (eight) months. Subjects were interviewed and trained includes 1 (one) Head of the Primary Health Center , 4 (four) outpatient filing personnel, 2 (two) inpatient filing personnel and 6 (six) patients of Mijen Primary Health Center Semarang. The secondary data sources are outpatient, emergency and inpatient register, medical record management policies, SOP of medical records management, expedition books, as well as MRD borrowing card. Moreover, researchers have carried out observations of active medical records management system in outpatient and inpatient filing, inactive and timeless at Mijen Primary Health Center as a basis for preparing SOPs. Results of the devotion to be expected to solve problems in active medical record management system reform in Mijen Primary Health Center which are still established in decentralization to centralization. Another method resulting is to fix the storage of family folder into 1 (one) folder for 1 (one) of a patient’s medical record number. Furthermore, achieve medical record documents (MRD) alignment model which has been implement Terminal Digit Filing (TDF) with six (6) digit medical record number, but still based on 10 (ten) sub region. Thus, retrieval of medical data are expected to be achieved. In addition, result in the retention schedule and inactive and timeless MRD implementation method. Kata kunci: MRD, active, incative, timeless, registration place, filing, outpatient, inpatient