PROSIDING PENGABDIAN MASYARAKAT POLTEKKES KEMENKES TASIKMALAYA

“Inovasi Pengabdian Masyarakat Sebagai Hilirisasi Penelitian

pada Masa New Normal dalam Upaya Mitigasi Kesehatan”, 26 Agustus 2021 - E-ISSN: 2807-9183

PENYUSUNAN PEDOMAN PENYELENGGARAAN REKAM MEDIS DI PUSKESMAS

MANONJAYA KABUPATEN TASIKMALAYA

Imas Masturoh1*, Dedi Setiadi2, Endang Triyanti3

1,2,3
Jurusan Rekam Medis dan Informasi Kesehatan Poltekkes Kemenkes
Tasikmalaya, Poltekkes Kemenkes Tasikmalaya

*imas.mth@gmail.com

Diterima: 26 Agustus 2021 Direvisi: 15 September 2021,

Diterbitkan: 20 Oktober 2021

ABSTRACT
Puskesmas is one of the first-level health facilities and is the spearhead of health
development. In its service, it is necessary to organize medical records in order to
produce quality and quality information. One of the efforts to improve the quality of
service in the medical record unit of the community health center requires guidelines for
organizing medical records that are adjusted to applicable regulations. At the
Manonjaya Health Center there is no guideline for organizing medical records so that the
implementation of medical record management has not been carried out optimally
because the officers who manage the medical record unit, including the registration
section, do not all have a medical record educational background so that not all officers
understand medical records. The method of this activity is through the identification
stage of existing medical record management guidelines, providing socialization and
assistance in compiling guidelines for medical record administration as well as
monitoring and evaluation. The results of identification and socialization showed that
most of the officers' knowledge was still less than the average score (average score: 77)
which was 63.6% while the good ones were only 36.4%, so intensive assistance was
needed to prepare the implementation of the guidelines. After the assistance was carried
out, the guidelines for organizing medical records at the Manonjaya Health Center were
compiled, including; Medical Record Management System; Medical Record Procedures;
Medical Activity Recording; Medical Record Forms and Methods; Medical Record
Processing; Legal Aspects of Medical Records. It is recommended that the medical record
service manual that has been made can be used as a guide at the Manonjaya Health
Center and set in the form of a decree from the leadership of the Manonjaya Health
Center.

Keywords: guidelines, medical records, community health centers

ABSTRAK
Puskesmas merupakan salah satu fasilitas kesehatan tingkat pertama dan sebagai
ujung tombak pembangunan kesehatan. Dalam pelayanannya perlu
menyelenggarakan rekam medis agar menghasilkan sebuah informasi yang
berkualitas dan bermutu. Salah satu upaya untuk meningkatkan mutu pelayanan di
unit rekam medis Puskesmas maka dibutuhkan pedoman penyelenggaraan rekam
medis yang disesuaikan dengan regulasi yang berlaku. Di Puskesmas Manonjaya
belum tersedia Pedoman Penyelenggaraan rekam medis sehingga pelaksanaan
pengelolaan rekam medis belum terlaksana secara optimal karena petugas yang

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