How to cite:

Ariska Nurlaila, Devita Farita. (2021) Review Procedures Borrowing and

Return Record Files Medical Outpatient Medical Record in Health Unit River

Candle. Journal Eduvest. 1(9): 898-901

E-ISSN:

2775-3727

Published by:

https://greenpublisher.co.id/

Eduvest – Journal of Universal Studies

Volume 1 Number 9, September 2021

p- ISSN 2775-3735 e-ISSN 2775-3727

REVIEW PROCEDURES BORROWING AND RETURN RECORD

FILES MEDICAL OUTPATIENT MEDICAL RECORD IN HEALTH

UNIT RIVER CANDLE

Ariska Nurlaila, Devita Farita

Piksi Ganesha Polytechnic Bandung

E-mail: [email protected], [email protected]

ARTICLE INFO ABSTRACT

Received:

August, 26

2021

Revised:

September, 10

2021

Approved:

September, 13

2021

The borrowing of medical record documents at the

puskesmas is used for internal or external purposes which

include needs in aspects of the usefulness of medical record

documents such as administrative, medical, legal, financial,

research, and educational aspects. Based on a survey at the

puskesmas, the procedure for borrowing and returning

medical record files has not been carried out effectively, for

example, the return of outpatient medical record files is often

not in accordance with the provisions, namely a maximum of

1 (one) hour before the end of working hours, thus hampering

the implementation of medical record retrieval at any time.

The time is needed by patients, doctors, and parties who need

medical record files. The purpose of this study was to

determine the procedure for borrowing and returning

outpatient medical record files. This research is a type of

descriptive research. The object of the research is the

procedure for borrowing and returning medical record files of

outpatients in the medical record unit. The instruments used

are observation guidelines and interview guidelines.

KEYWORDS

Procedure For Borrowing, Prosedur For Returning, Medical

Record, Human Resources

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Ariska Nurlaila, Devita Farita

Review Procedures Borrowing and Return Record Files Medical Outpatient Medical

Record in Health Unit River Candle 899

INTRODUCTION

Puskesmas is a technical implementation unit of the district / city health office that

is responsible for organizing health development in a work area (Harianja, 2018).

Medical records are files containing records and documents about the patient's identity,

examination, treatment, actions and other services that have been provided to the patient

(Hendrawan, Winardi, & Surbakti, 2017).

Medical Record Unit that supports in medical record services is a storage room

(filing) where outpatient, inpatient and emergency medical records are stored because

medical records are confidential and have legal aspects (Mathar, 2018). A procedure is a

sequence of activities established to ensure the uniform handling of transactions that

occur repeatedly (IRAWAN, 2018).

Medical records officer responsible for where the medical records file and the

entire medical records that are still in the service units (Guswani, 2016). When the

medical records are outside the medical record unit, the medical records officer is

responsible for where the medical records file is sent and as much as possible know at

any time the existence of the medical record file in the service units (Yuliani & Utami,

2016).

Therefore, the need to apply the procedure of borrowing and returning medical

records files, while those who are entitled to borrow medical records files are those

responsible for the patient, namely doctors, nurses and medical personnel who are

responsible for the confidentiality of medical records files (Valentina, 2019).

The terms of borrowing medical records files are that the identity must be clear

whether borrowing or having a medical record file (Nofiana & Sugiarsi, 2011), the

location of the loan is carried out in the office of the medical record unit itself, outside the

agency / outside the hospital, there is evidence in the medical record unit, tracers at the

location / storage rack of medical records documents, medical records that must be used

must be complete (Pasaribu & Sihombing, 2017).

In the sop puskesmas, the medical record to be returned must be completed first by

the room attendant (Lestari & Muflihatin, 2020). After being completed and written on

the room expedition book, the document is returned to the medical record unit (Fauziah &

Sugiarti, 2014).

Delay in return resulting in the buildup of medical record documents, in the

recording on the register book has not been in accordance with the date the patient

returned so that the recording of medical record documents becomes irregular and can be

difficult if the document is needed again for further treatment and cause delays in the

management of data and health care reports (Medis, 2015).

Based on the survey at the health center, the procedure of borrowing and returning

medical records files has not been implemented effectively, for example, the return of

medical records files is not in time so as to hinder the re retrieval of medical records that

are at any time needed by patients, doctors, and parties who need medical records files

(MAHENDRA, 2019). This is due to the lack of good facilities and infrastructure and the

lack of medical records personnel who take care of the procedure of borrowing and

returning medical records files.

RESEARCH METHOD

The method used in this research is descriptive, the author only observes the

object of research to find out the existing problems and find ways to solve them. The

Eduvest – Journal of Universal Studies

Volume 1 Number 9, September 2021

900 http://eduvest.greenvest.co.id

object of research is the procedure for borrowing and returning medical record files at the

medical record unit at Sungai Wax Public Health Center. Research Instruments use

interview guidelines and observation guidelines.

RESULT AND DISCUSSION

A. Research Results

1. Procedures for borrowing documents and returning medical records

At the medical record unit of the Sungai Candle Health Center have human

resources which have 2 storage officers in charge of serving the borrowing and returning

of medical record documents. This loan is based on the Regulation of the Minister of

Health of the Republic of Indonesia No. 269/MenKes/PER/III/2008, article 13 chapter V

concerning Ownership, Utilization and Responsible Person, namely the medical record

document belonging to the health service facility while the contents of the medical record

belong to the patient.

2. Procedures regarding borrowing medical record documents, namely:

a) The borrower submits a loan receipt to the head of the medical record

b) The head of the medical record submits a loan receipt to the storage department

to retrieve the documents to be borrowed

c) After the medical record document is received by the borrower, the borrower

signs the loan receipt book.

3. Procedures for returning medical record files are:

a) Documents returned must be recorded in the expedition book and signed

by the medical record officer.

b) Must include the date of return, the name of the borrower and the

borrower's signature.

B. Discussion

The procedure for borrowing and returning has been implemented well, it can be

seen where the medical record file is returned to the medical record unit on time (Sugiarti

& Prodi III, 2020). but there are differences in terms of implementation in the field due to

the lack of responsibility of medical record officers in borrowing and returning medical

record files such as not completing the filling in the loan receipt book, and from the

results of the study that the rate of return of outpatient medical records amounted to 5

files which were recorded in the book loan receipts that are returned on time (Fenwick,

McCahery, & Vermeulen, 2017).

Meanwhile, supporting facilities and infrastructure in the implementation of

borrowing and returning files are adequate. With the availability of supporting facilities

and infrastructure, it makes it easier for officers to borrow and return without any

obstacles or obstacles in carrying out these tasks.

CONCLUSSION

Based on the results of the discussion, it can be concluded that the procedure for

borrowing and returning medical records is carried out based on SOPs but in terms of

implementation there is still less responsibility for medical record officers such as not

completing the filling in the loan receipt book. Books, notes and forms used in borrowing

medical record documents are tracer, loan receipt book, piece of paper (functions the

same as loan receipt). In borrowing and returning medical record files, it is still not

running effectively so that many loan receipt books are not filled out completely

Ariska Nurlaila, Devita Farita

Review Procedures Borrowing and Return Record Files Medical Outpatient Medical

Record in Health Unit River Candle 901

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