Qualitative Study of Inpatient Medical Record Analysis atPatut Patuh Patju Regional Hospital in 2023
DOI:
https://doi.org/10.37824/j81set76Keywords:
assembling coding, filing, medical record files, issues, assembling, coding, filling, qualitativeAbstract
The hospital, as a vital component of the healthcare system, provides services to the community through its emergency unit, outpatient care, and inpatient services. Medical records are files containing notes and documents about patient's identity, examinations, treatments, and other services rendered to the patient. The objective of this research is to understand the processing of inpatient medical record files within the medical records unit, as well as the issues present in the assembling, coding, and filing stages. This study employs a descriptive methodology with a qualitative approach. The data collection methods included observation, interviews, and documentation involving three respondents. The analytical technique applied is qualitative analysis, which compares the realities observed in the field with existing theories. The results of this study reveal the process of managing inpatient medical record files at the Patut Patuh Patju Gerung Regional Hospital, begins with: assembling, coding, and filing. The implementation of medical record processing has not yet fully complied with the established Standard Operating Procedures. The coding process has been carried out in accordance with ICD standards. The filling system employs a centralized approach using the terminal digit filing method. The limitation of human resources serves as the primary obstacle in both the assembling and coding sections. The issues encountered in the assembling section include delays in returning medical record files to the medical records unit exceeding 1x24 hours; in the coding section, there are diagnoses that are illegible; and in the filing section, there are instances of misfiling, voluminous records, and loose sheets.
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