Analisis Pengolahan Rekam Medis Rawat Jalan di Rumah Sakit Gigi dan Mulut Universitas Sumatera Utara

Abstract

A medical record is a file that contains records and documents about patients' identity, examination, treatment, and other medical actions at healthcare facilities for outpatient and inpatient, both managed by the government and private institutions. This study aimed to discover the process of managing outpatient medical records at the University of North Sumatra Dental and Oral Hospital (RSGM). This study used a descriptive method with a qualitative approach. The informants in this study were the heads of medical records and medical records officers. In this study, researchers used various techniques in data collection, namely observation, interview, and documentation. The data sources used are primary data and secondary data. Data analysis techniques are reduction, presentation, conclusion, and verification. Data testing used triangulation, namely source, technique, and time triangulation. The results showed that the process of managing outpatient medical records at the University of North Sumatra Dental and Oral Hospital (RSGM) based on the guidelines for organizing hospital medical record procedures in Indonesia (2006) includes structuring medical record files, coding, tabulation, hospital statistics and reporting, medical record correspondence, medical record analysis, medical record storage systems, medical record retrieval systems, shrinkage, and destruction of medical records. The analysis of outpatient medical records processing at the University of North Sumatra Dental and Oral Hospital showed that they followed procedures according to hospital guidelines.