Fakultas Kesehatan Masyarakat Universitas Airlangga
Abstract
Information in the medical record could be used for various purposes, such as treatment decisions for patients, evidence of legal services provided and the evidence on the performance of human resources in health care facilities. Preliminary research has foundthat incomplete medical record in Usada Sidoarjo Hospital of 76,67% and 90,42%.This study aimed to evaluate the process of report creation and utilization of information in medical Record Unit UsadaHospital Sidoarjo.This was cross-sectionalstudy. Data was collected through observation as well as interviewing to the hospital middle level managementwhich then compared withGuidelines for Hospital Medical Record in Indonesia. Theprocess of recapitulation of patients visits, hospital activity reported, and internal reported hospitals were already fits with the guidelines. While the resumes settlement process, daily inpatient censusreporting, morbidity reported process, and external reported hospitals still were not in line with the guideline. Some effort can be made to improve the reporting process. Medical record officer could use ICD-10 applicationto getting the medical record code. Moreover to increase performance in external reporting, it needs to strengthen the role of each unit in organizational structure of medical record
