Tinjauan Pelaksanaan Prosedur Pengembalian Dokumen Rekam Medis Rawat Inap Pasien Covid-19 di Rumah Sakit Budi Asih Trenggalek

Abstract

The study aimed to evaluate the procedure for returning Covid-19 patients' medical record documents at Budi Asih Hospital, Trenggalek. Using descriptive qualitative research, observation, and interviews, the study focused on inpatient medical record documents, nurses, and medical record officers. Accidental and simple random sampling techniques were employed. The procedure followed the SOP stated in circular number HM.01.01/002/III/2020. While the document management during treatment adhered to the SOP, post-hospitalization management deviated from the established guidelines, such as not using yellow plastic, cardboard boxes, leaving documents for 5 days, and not cleaning them before processing. Implementations the document for Covid-19 patients management process as long as the patient was in treatment in accordance with the SOP, while document for Covid-19 patients management after the patient returned from hospitalization was not in accordance with the established SOP, such as medical record documents of Covid-19 patient were not put in yellow plastic, were not put in cardboard boxes, were not left for 5 days and medical record documents were not cleaned before paper is managed.