Management of medical record in installation of inpatient regional public hospital Batara Guru Belopa

INTRODUCTION

Hospitals are health care facilities that are absolutely needed by all levels of society in an effort to improve the health status of both individuals and society as a whole.¹ One indicator to assess the quality of a health service in a hospital is the availability of a complete and accurate medical record. According to Regulation of the Minister of Health No. 269 / Menkes/ Per / III / 2008 medical records are files that contain records and documents about patient identity, examination, treatment, actions and other services that have been given to patients. The main uses of medical records are as evidence of the patient's illness (doctor's diagnosis) and treatment that has been given, communication tools among health staff who provide care to patients, sources of information for research and education, and as sources in collecting health statistics.²

A good medical record contains complete data and can be processed into information, thus allowing an objective evaluation of the performance of health services and can be the basis of education, research and development. The main responsibility for completing the medical record lies in medical personnel responsible for treating the patient. Completeness of writing in medical record file is an important matter. Incomplete medical records will not be sufficient to provide information for further treatment when the patient returns to the health care facility. Every recording in medical record must be given name, time and signature of the medical personnel or certain health personnel who provide health services directly. The documentation must be complete, because the main purpose of the medical record is to enable medical personnel to provide quality services and health care for patients.³

The complete analysis of filling in medical record document is one indicator of the assessment of service quality at the hospital concerned. The fewer numbers of incompleteness in filling the medical record file, the better the quality of service for a hospital. Based on the preliminary observation data at the Regional Public Hospital Batara Guru Belopa, the medical record file storage facilities and infrastructure are still lacking compared to the large number of patients. The medical record file received by the Medical Record in Installation of inpatient Regional Public Hospital Batara Guru Belopa is still incomplete so it cannot reflect good administrative order. So that in this study an analysis of the medical record management of patients in Installation of Inpatient Regional Public Hospital Batara Guru Belopa will be analyzed.

METHODS

The type of research used in this study is qualitative research. This study was conducted at the Installation of Inpatient Regional Public Hospital Batara Guru Belopa, which was conducted for one month. This hospital was chosen as the research site because it was the only government hospital in Luwu Regency and had received recognition from the Hospital Accreditation Commission as a fully accredited hospital in 2018, so researchers wanted to further analyze the management of medical recording in Installation of Inpatient Regional Public Hospital Batara Guru Belopa. The informants in this study were 18 people who were determined based on purposive techniques, namely techniques that were conducted to select informants who were willing and able to provide information relating to the topic of research.

Informants consisted of key informants and other informants (triangulation informants). Data collection techniques in this study were observation, in-depth interviews and document review.⁴ Data collected consists of primary and secondary data.The analysis technique used in this study is done through the flow of raw data collection, data transcripts, coding creation, data categorization, temporary inference, triangulation and final conclusion.

RESULTS

Public Hospital Batara Guru Belopa in Luwu regency was inaugurated by the Governor of South Sulawesi on August 4, 2005 and was officially opened and activated on September 28, 2005. With an area of 3,000.25 km² or 4.81 of the land area of South Sulawesi Province, located in the northern part of South Sulawesi Province or the east coast of South Sulawesi. Regional Public Hospital Batara Guru Belopa is a type C hospital with a type of service based on Director's Decree Number: 800/175 / RSUD-BG / XII / 2017 concerning the services of the Batara Guru Hospital.

In this study, informants used a total of 18 people. The informants included the Secretary of Batara Hospital teacher, head of medical record section, head of medical record room, implementing medical record assembling section, implementing medical record section and implementation of filling medical record, surgeon, head of surgical treatment room, nurse in surgical care room, doctor of internal medicine, head of internal care room, nurse in internation room, pediatrician, head of child care room, nurse in child care room and gynecologist, head of midwifery care room and midwife in midwifery care room. The length of time the informant works starting from 2 - 12 years.As for more clearly the characteristics of informants can be seen in the Table 1 as follows:

Interactions between service providers and recipients or patients in the health sector are closely related and sustainable. Therefore to improve the quality of services to be provided and to monitor a person's medical history, each safety service provider is required to make a medical record. In the field of medicine and dentistry, medical records are one of written proofs of the process of service provided. In the medical record contains patient clinical data during diagnosis and treatment process. Therefore every medical service activity must have a complete and accurate medical record for each patient, and every doctor and dentist must fill the medical record correctly, completely and on time as well as the hospital as one of the health care facilities also required to make medical records.

Human resources

Human resources at the medical record installation take an important role related to the processing of medical record files. The continuity of the medical record processing depends on medical record officer so that it will produce a complete, accurate and timely medical record. Based on the results of interviews with the hospital management section, the efforts made to improve quality of the work were by training or training both by the hospital and by sending personnel to the province. Based on the results of interviews with informants about medical personnel routinely attending training on filling in medical record files held by the hospital, informants basically stated that routine medical personnel/ always followed if there was training in filling out medical record files held by the hospital, even though there were still personnel who have not participated because at the time activity is unable to attend.

Based on the results of interviews and document review, it can be concluded that the paramedics in charge of being installed inpatients routinely attend training on filling in the medical record files held by the hospital. Completing the medical record is a process of filling out completely and clearly all actions against the patient in a medical record document. The document is a very important thing to be used as an evaluation of quality of services provided to patients. Based on the results of interviews with informants about the causes of filling in incomplete medical record files, that is caused by the rush of doctors or in a hurry, so negligent in filling out medical records. Based on the results of the interview and document review, it can be concluded that if medical record document is incomplete, the nurse will contact the doctor in charge of the service to obtain information to complete document.Based on the results of interviews regarding the main duties of the officers and the obstacles in carrying out them, basically the officers, both medical records and inpatient installations, all carried out their duties without any obstacles, although in the medical record there were officers who were not the main task but kept running.

Procedure

The process of processing medical records of inpatients consists of assembling, coding, and filling processes. Based on the results of interviews with informants regarding the flow of the implementation of medical record at the inpatient unit above, it can be concluded that basically the officers already know but there are still some officers who do not understand well about the flow of the entry of medical records in the inpatient installation.

Information

Policy is a series of concepts that serve as guidelines and basic plans for implementing filling in medical records.Based on the results of interviews with informants about hospital policy about filling out the medical records, all informants said that the implementation of hospital policies regarding filling in medical records had been socialized and they had implemented the policy even though it was not optimal because there were medical records that were slowly completed.

Based on the results of interviews with the above informants regarding obstacles and constraints in managing medical records both in medical record installations and inpatient care, information was obtained that management of medical records was an obstacle for hospital drivers who had not been connected to treatment because computer facilities were not yet available. Because the filling is not complete and preparation of the contents of the medical record is sometimes not in the order. Based on the results of interviews with the management of the Batara Guru Belopa Hospital, information was obtained that the evaluation of medical records was carried out 3 to 4 times a year so that efforts were made to improve services in the medical record section. From the results of interviews with informants regarding the facilities and infrastructure at the medical record installation, it can be concluded that facilities and infrastructure are still lacking and while the main improvement is the hospital information management system.

DISCUSSION

The role of medical records as a source of information for both patients and hospitals must be fully and accurately documented in each form. Data in a complete medical record form will facilitate decision making. Therefore, to be able to provide complete and accurate information on the completeness of the data in filling out the form, it must be considered.⁵ Management of the completeness of medical record documents is one way to assess how the quality of services at the hospital is concerned. The fewer numbers of incompleteness, the better the quality of service.

Human resources

Human resources are a very important factor that cannot even be separated from an organization, both institutions and companies. Human resources are also one of the keys that can determine development of company. One effort to reduce or eliminate the gap between abilities of each employee can be done through training by increasing the work ability of each employee by increasing knowledge, skills and changing attitudes and behavior. According to Aditama the head of the hospital is responsible for providing adequate training and technology for each employee.⁶ According to Soeprihantio as quoted by Dwi Susanto states that benefits of training and development include productivity increases in both quantity and quality, increase in work morale, reduce supervision, personal development. Based on the results of interviews with informants, it can be concluded that routine medical personnel/ always follow if there is training on filling in medical record files held by hospitals or training conducted at the provincial level.⁷ Officers who have received training have the opportunity for higher and higher performance compared to officers who have never been trained. The training provided refers to the development of work skills that can be used immediately so that they can have a positive influence on the performance of employees concerned.⁸

Procedure

The work procedure is a guideline or reference in carrying out work duties in accordance with functions and tools of performance appraisal of government agencies based on technical, administrative, and procedural indicators according to work procedures, work procedures and work systems in the work unit concerned. Standard operational procedure (SOP) is a guideline in carrying out work tasks in accordance with functions and tools of performance appraisal of government agencies based on technical, administrative and procedural indicators of work procedures, work procedures and work systems in the work unit concerned.⁹ In the hospital medical record management manual (1997), the medical record category includes other summaries of entry and exit; physical examination; chart sheet; the course of illness, doctor's orders, and treatment; records of nurses or midwives; results of laboratory tests; resume out; special control sheet; operating report; anesthesia report; history of pregnancy; labor records; baby identification; and medical treatment/ action approval.

The procedures and flow of medical records are installed inpatient at Regional Public Hospital Batara Guru, where patients arrive at the Registration Place for Inpatients whether there is a request from a doctor, emergency room, or referral from a health center. The medical record flow as shown in Figure 1.

Based on the results of in-depth interviews with informants, information was obtained that the procedure for processing medical records was in accordance with the Permenkes No.269 / Menkes / Per / III / 2008 flow of medical records starting from medical record section then to the inpatient installation and returned to medical assembling section after the patient returns then to the coding section to be given an action code and the diagnosis code then brought to the filling section to be stored. Hutama's research, the implementation of medical records at PKU Muhammadiyah Yogyakarta Hospital both for polyclinic services and emergency services and hospitalization started from registration process and interviews with officers in the registration section.¹⁰

Then the registration and interview process to fill identity of the new patient which is then followed by giving patient card accompanied by a barcode containing the medical record number that must be carried by the patient during the return visit to the hospital. Whereas the old patient only registered and handed over the patient card which would then be searched for a medical record file by administration officer. The medical record process is done manually by the doctor in each patient's medical record file after providing services and then it will be determined whether the patient needs inpatient services or not. If not, the medical record file is immediately returned to the medical record unit for further storage.

Information

Information becomes very important in the health care system, whether it is a medical record in the form of manual or electronic, which is a source of medical information that describes all aspects of patient care. The problem that usually arises in process of managing medical records is the lack of clarity in the doctor's writing on the medical record file, thus inhibiting the process of coding the diagnosis of the patient's disease. This will require a long time for confirmation process, especially if there is no common perception among health workers about the importance of filling in and writing in the medical record file.¹¹

Based on the results of the interview, it was found that there was a policy regarding the management of medical records that regulated the system to achieve orderly administration and improvement of health services. One of the policies refers to the old government regulation, Permenkes No.749a / MENKES / XII / 1989.

CONCLUSION

Managing the medical record completeness of patients in the Installation of Inpatient Regional Public Hospital Batara Guru Belopa in terms of human resources, namely the number of staff still needs to be added, especially in the center of hospitalization by looking at the large number of patients and staff workloads. Medical record held by the hospital. Based on filling, doctors rarely fill in complete medical record sheets. Based on the duties and functions of each officer both the medical record section and the maintenance department all run well and there were no obstacles in carrying out it. The procedure in managing the medical record completeness of patients in Installation of Inpatient Regional Public Hospital Batara Guru Belopa is based on medical record processing procedures where the medical record processing procedures are in accordance with the Permenkes No.269 / Menkes / Per/ III / 2008 flow of medical records. Information in managing the medical record completeness of patients in the Installation of Inpatient Regional Public Hospital Batara Guru Belopa, which is based on hospital policy No: 023 / RSUD-BG / I / 2016 concerning filling medical records.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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