Manajemen Pengembalian Berkas Rekam Medis di ruang rawat Inap Penyakit dalam

Abstract

Medical record retrieval management is a crucial part of hospital management because it is related to the smooth flow of data processing, reporting, and the quality of healthcare services. Medical records contain information about patient identity, examination results, diagnoses, medical procedures, and healthcare services provided during the patient's treatment. This study aims to examine the management of medical record retrieval in an internal medicine inpatient ward. This study used a descriptive method with a quantitative approach and was conducted in a hospital in South Sumatra Province over three weeks with 23 nurses as respondents. Data collection was conducted using a questionnaire developed based on standard operating procedures for medical record retrieval, and then analyzed descriptively. The results indicate that most nurses demonstrate initiative, responsibility, work motivation, and good teamwork in retrieval of medical records. However, several aspects still need improvement, such as discipline in completing tasks and individual responsibility, to ensure a more orderly, timely, and optimal process for retrieval of medical records, supporting healthcare services in the hospital.