Salsa Maria Margareta, Agustina Pujilestari

Tinjauan Pelaksanaan Pemeliharaan Dokumen Rekam Medis di Ruang Filling: Studi Kasus di RSUD dr. Soeratno Gemolong

Introduction

Tinjauan pelaksanaan pemeliharaan dokumen rekam medis di ruang filling: studi kasus di rsud dr. Soeratno gemolong. Studi kasus di RSUD dr. Soeratno Gemolong menyoroti suboptimalnya pemeliharaan dokumen rekam medis. Masalah: keterbatasan ruang, digitalisasi lambat, risiko kerusakan. Rekomendasi perbaikan manajemen.

Abstract

Rumah Sakit Umum Daerah dr. Soeratno Gemolong mulai tahun 2025 diketahui bahwa sudah tidak terdapat petugas khusus filling sehingga tidak ada lagi petugas yang melaksanakan fungsi pengelolaan dokumen rekam medis. Penelitian ini bertujuan menganalisis untuk pelaksanaan pemeliharaan dokumen rekam medis di ruang penyimpanan serta faktor-faktor yang mempengaruhinya.  Penelitian menggunakan metode pendekatan deskriptif kualitatif melalui wawancara mendalam, observasi, dan telaah dokumen. Informan terdiri dari dua orang, yaitu Kepala Unit Rekam Medis dan satu staf rekam medis yang berpengalaman lebih dari 4 tahun dan 14 tahun di bidang kearsipan. Proses analisis dilakukan melalui reduksi data (pemilihan informasi relevan), penyajian data (narasi deskriptif dan tabel tematik), serta penarikan kesimpulan dengan membandingkan temuan dan teori. Hasil penelitian menunjukkan bahwa rumah sakit telah memiliki kebijakan, Standar Operasional Prosedur (SOP), dan buku pedoman terkait pemeliharaan dokumen, namun implementasinya belum maksimal. Dua temuan kunci adalah (1) keterbatasan ruang penyimpanan menyebabkan sebagian dokumen ditumpuk di lantai, meningkatkan risiko kerusakan; (2) program alih media (digitalisasi) berjalan lambat sehingga arsip manual menumpuk dan rentan terhadap faktor ekstrinsik seperti kelembapan dan serangga. Pemeliharaan faktor intrinsik seperti penggantian map belum dilakukan secara rutin, sementara perlindungan terhadap faktor biologis masih sebatas fogging dua bulan sekali tanpa penggunaan kamper. Disimpulkan bahwa pemeliharaan dokumen rekam medis di RSUD dr. Soeratno Gemolong masih belum optimal. Disarankan penguatan kebijakan larangan makanan dan minuman, percepatan digitalisasi, pelatihan berkala untuk petugas, dan audit internal guna memastikan kepatuhan SOP.

Review

This study, titled "Review of Medical Record Document Maintenance Implementation in the Filing Room: A Case Study at RSUD dr. Soeratno Gemolong," addresses a critical operational aspect within healthcare facilities. The research is particularly timely and relevant given the stated context that RSUD dr. Soeratno Gemolong will no longer have dedicated filing personnel from 2025, which underscores the urgency for robust and sustainable document management practices. The primary objective of this qualitative descriptive study was to analyze the current implementation of medical record document maintenance in the storage area and identify the factors influencing its effectiveness, thereby providing valuable insights into a pressing issue faced by many hospitals. The research employed a qualitative descriptive approach, utilizing in-depth interviews with the Head of the Medical Records Unit and an experienced medical records staff, alongside observations and document reviews. The data analysis followed a structured process of data reduction, presentation, and conclusion drawing. The findings reveal that while the hospital possesses the necessary foundational elements—policies, Standard Operational Procedures (SOPs), and guidelines for document maintenance—their implementation remains suboptimal. Key issues highlighted include severe space limitations leading to documents being stored on the floor, thus increasing their vulnerability to damage, and a slow digital conversion program that exacerbates the accumulation of manual archives. Furthermore, the study points out deficiencies in routine intrinsic maintenance, such as folder replacement, and inadequate protection against biological factors, with fogging being performed only bi-monthly without the use of camphor. In conclusion, the study unequivocally demonstrates that the maintenance of medical record documents at RSUD dr. Soeratno Gemolong is far from optimal, posing significant risks to data integrity and operational efficiency, particularly with the impending reduction in dedicated staff. The recommendations put forth are practical and pertinent: strengthening enforcement of no-food/drink policies, accelerating the digitalization process, implementing regular training for personnel, and conducting internal audits to ensure SOP compliance. These recommendations, if diligently implemented, could substantially improve the current state of medical record management and mitigate the risks associated with the identified shortcomings, ensuring better data security and operational readiness for the challenges ahead.

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