Analisis sistem pelaporan rekam medis pasien rawat jalan pada poli anak di rumah sakit X: Sebuah studi kualitatif

Abstract

Abstract Background: Facilities that provide comprehensive individual health services, including emergency, inpatient, and outpatient are called hospitals. In accordance with service standards, all hospitals are required to provide accurate information about their services to the general public and prioritize the needs of their patients, in order to provide safe, quality, and non-discriminatory health services. Medical records are defined as documents containing information about the patient's name, examination results, treatment, actions, and other services received. Medical records are used for patient health maintenance and treatment, data needs for academic research, the basis or reference for payment of medical bills, and health statistics data. Purpose: To determine the reporting of outpatient medical record analysis in the children's polyclinic of hospital X. Method: Descriptive qualitative research using data collection techniques by conducting direct field studies and interviews. The contributors of information in this study were 4 people who worked at hospital X in the fields of management, business development and IT, and medical records. Results: The number of children's polyclinic patients in February-March was 1,610 people with details of outpatients in February as many as 802 people and March as many as 808 patients. It is known that the average number of daily visits to children's polyclinic patients in February 2024 was 29 people, while in March 2024 there were 26 people. The problems found were that the average number of outpatient visits to children's polyclinics in February to March was unstable and the reporting system for outpatient medical records was carried out using Ms. Excel, resulting in the reporting system being implemented being less effective and efficient. Conclusion: The outpatient medical record reporting system at Hospital X is implemented using Ms. Excel which takes a long time and reduces the effectiveness of the reporting system implemented. Suggestion: In order to increase patient visits so that there is no instability of visits to the children's polyclinic, the hospital must improve supporting service facilities. In addition, to be more effective and efficient, medical recorders should use digital medical record applications, such as hospital management information system applications. Keywords: Outpatient Medical Record; Pediatric Clinic; Reporting System.