Implementation of Electronic Medical Record System

Oct 13, 2025 by leolavanderia.com.br 26 views

Analysis of Inpatient Medical Record Processing at the Pratama Kesuma Bangsa Clinic Sei Plate Asahan Regency

Introduction

The management of inpatient medical records is a crucial aspect of the healthcare system, playing a vital role in ensuring the quality of services provided to patients. In this study, we aim to analyze the management of inpatient medical records at the Kesuma Bangsa Pratama Clinic located in Sei Plate, Asahan Regency, North Sumatra. This clinic is situated on Jalan Lintas Sumatera, Rahuning II Village, Rahuning District, and serves as a primary healthcare facility for the local community.

Methodology

This study employed a descriptive research method to collect data from primary and secondary sources. Three informants were involved in this study, consisting of the head of the clinic and two medical record staff. Data collection was carried out through observation, interviews, and documentation, as well as triangulation techniques for sources and time. The data obtained were analyzed through a data reduction process, data presentation, and drawing conclusions to find relevant and meaningful information.

Results

The results of this study describe the management of inpatient medical records at the Kesuma Bangsa Pratama Clinic. The medical record management process starts from receiving medical record documents, recording in the expedition book, to storage in the box. The coding process is only found on the storage rack, while indexation is done by showing an identity card or BPJS card, which is then recorded in the ledger. There is only one internal report compiled, including reports of the patient in, the patient out, the patient who died, the birth, and the patient being treated. Correspondence is carried out through the manufacture of referral letters, treatment letters, and patient expenditure letters. The analysis process is carried out by re-checking to ensure there is no incomplete medical record.

Storage and Destruction of Medical Records

Storage of medical records is carried out with a centralized system, with a 5-year storage period. To take a medical record, the patient is required to show the identity card or BPJS card to the medical record officer, and the officer will find a medical record on the storage rack. The process of destruction of medical records is carried out after the age of the medical record reaches 3 years, by being destroyed or burned.

Additional Analysis and Explanation

Management of inpatient medical records is one important aspect in the health service system. In the Kesuma Bangsa Pratama Clinic, the application of systematic procedures in managing medical records shows efforts to maintain the quality of services to patients. The coding and indexation process used helps in organizing patient data more effectively, facilitating access to information, and minimizing the risk of data loss.

The importance of correspondence in the form of referral letters and expenditure letters cannot be ignored, because this functions as a bridge of communication between clinics and patients. The resulting internal report provides an overview of the statistics of patients who enter and exit, which can be a reference in making strategic decisions in the clinic.

The centralized storage system for five years reflects the clinical commitment to maintain a structured medical record, making it easier to retrieve data when needed. On the other hand, the destruction of the medical record that is no longer valid after three years shows clinical compliance with regulations regarding the privacy and security of patient data. This is important to avoid data abuse and maintain the confidentiality of patient information.

Conclusion

Overall, analysis of medical record processing at the Kesuma Bangsa Pratama Clinic shows the application of the best practices in the management of medical records. With a clear and systematic procedure, this clinic can provide better and more organized services, as well as support the improvement in the quality of public health in Asahan Regency.

Recommendations

Based on the findings of this study, the following recommendations are made:

Implementation of Electronic Medical Record System: The clinic should consider implementing an electronic medical record system to improve the efficiency and accuracy of medical record management.
Standardization of Medical Record Format: The clinic should standardize the format of medical records to ensure consistency and ease of access to information.
Training and Education: The clinic should provide regular training and education to medical record staff on the importance of medical record management and the procedures for managing medical records.
Regular Audits and Quality Control: The clinic should conduct regular audits and quality control measures to ensure that medical records are accurate, complete, and up-to-date.

By implementing these recommendations, the Kesuma Bangsa Pratama Clinic can further improve the management of inpatient medical records and provide better services to patients.
Frequently Asked Questions (FAQs) about Inpatient Medical Record Processing at the Pratama Kesuma Bangsa Clinic Sei Plate Asahan Regency

Q: What is the purpose of inpatient medical record processing?

A: The purpose of inpatient medical record processing is to ensure the accurate and efficient management of patient information, which is essential for providing quality healthcare services.

Q: What are the key steps involved in inpatient medical record processing?

A: The key steps involved in inpatient medical record processing include receiving medical record documents, recording in the expedition book, coding, indexation, storage, and destruction of medical records.

Q: What is the significance of coding and indexation in medical record processing?

A: Coding and indexation are essential in organizing patient data more effectively, facilitating access to information, and minimizing the risk of data loss.

Q: How does the clinic ensure the confidentiality and security of patient data?

A: The clinic ensures the confidentiality and security of patient data by implementing a centralized storage system with a 5-year storage period and destroying medical records that are no longer valid after 3 years.

Q: What is the importance of correspondence in medical record processing?

A: Correspondence is essential in medical record processing as it functions as a bridge of communication between clinics and patients, facilitating the exchange of information and ensuring that patients receive the necessary care.

Q: How does the clinic maintain the quality of services to patients?

A: The clinic maintains the quality of services to patients by applying systematic procedures in managing medical records, ensuring that patient data is accurate, complete, and up-to-date.

Q: What are the benefits of implementing an electronic medical record system?

A: Implementing an electronic medical record system can improve the efficiency and accuracy of medical record management, reduce the risk of data loss, and enhance patient care.

Q: How can the clinic improve the management of inpatient medical records?

A: The clinic can improve the management of inpatient medical records by standardizing the format of medical records, providing regular training and education to medical record staff, and conducting regular audits and quality control measures.

Q: What are the implications of non-compliance with regulations regarding the privacy and security of patient data?

A: Non-compliance with regulations regarding the privacy and security of patient data can result in data abuse, confidentiality breaches, and reputational damage to the clinic.

Q: How can the clinic ensure that medical records are accurate, complete, and up-to-date?

A: The clinic can ensure that medical records are accurate, complete, and up-to-date by implementing regular audits and quality control measures, providing regular training and education to medical record staff, and ensuring that medical record staff are aware of the importance of accurate and complete medical record management.

Q: What is the role of medical record staff in ensuring the quality of services to patients?

A: Medical record staff play a crucial role in ensuring the quality of services to patients by accurately and efficiently managing patient information, ensuring that medical records are accurate, complete, and up-to-date, and providing support to healthcare professionals in making informed decisions about patient care.