Analysis of the implementation of medical record services in Ibnu Sina Islamic Hospital in 2019

Abstract

Background: Medical records are important files or documents for each hospital institution. The process of organizing medical records begins when the patient is received at the hospital, followed by the recording of patient medical data by doctors or dentists or other health professionals who provide direct health services to patients. The objective of the study was to find out the implementation of inpatient medical record services at Home Ibnu Sina Hospital, Padang in 2019.Methods: Qualitative with a system approach of input, process, and output. Research informants was 5 people.Results: In making a decision and policy, not all parties were included, such as medical personnel, paramedics, and medical records officers, tools and materials that support the implementation of medical records, especially where the storage of active medical records is not yet available.Conclusions: The implementation of medical records at RSI Ibnu Sina Padang in 2019 has not been carried out thoroughly as seen from the input, process and output. For this reason, the addition of an active medical record repository, the existence of coordination, integration and synchronization in making decisions and policies so that medical personnel, paramedics and medical records officers are included.