Sheona, Oktaveri (2023) GAMBARAN PENYELENGGARAAN REKAM MEDIS DI RUMAH SAKIT ISLAM BANJARMASIN. [Tugas Akhir]

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Abstract

ABSTRACT The system for administering medical records in hospitals is the process of admitting outpatients, inpatients and emergency departments. Quantitative and qualitative data analysis, data processing, namely coding diseases and actions by inputting the INA-CBGs software. Providing indexes that have been coded, reporting data in the Hospital Information System (SIRS) both internally and externally. Medical record files that have been reported will then be stored on storage shelves and also computers where if the patient returns for treatment it will make it easier for officers to provide files, the benefit of organizing medical records itself is useful for creating an orderly administration in a health institution. Administrative order is one of the main aspects in efforts to improve health services in hospitals. The purpose of this study was to find out the description of medical record management at Banjarmasin Islamic Hospital. This study used a descriptive method with 4 respondents. The results of this study include regulations related to the administration of medical records including decrees (SK), guidelines, and standard operating procedures (SPO). Then the medical record administration unit, and the flow of medical record administration which includes the registration flow, the distribution flow, the clinical information filling flow, the patient information processing flow, and the medical record storage flow at the Banjarmasin Islamic Hospital. Keywords: Organizing unit, Medical record, Hospital, Electronic medical record

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