ACCREDITATION OF MEDICAL RECORDS IN PRIMARY CARES

Abstract

Accreditation for primary cares is required and regulated in the Republic of Indonesia Minister of Health Regulation Num. 46 of 2015 Article 3. Although primary cares have been accredited, the management of medical records in primary cares has not been perfectly marked by lack of security and confidentiality of patient medical records. Therefore, research on the management of medical records based on accreditation is very important to create good administration. The aim of this study was to evaluate management of medical records in primary cares based on accreditation for primary cares and applicable legislation. Research is a qualitative research, so data collection is done by participatory and systematic observation, non-guided interviews and discussions, and documentation. Data processing starting from editing data continue triangulation data. Analysis and presentation of data is done qualitatively and quantitatively. Observations were made on the management of medical records in primary cares, interviews with medical record managers in primary cares, and reviews of medical record documents and supporting documents in the medical record management process. Result indicated that Standard criteria 8.4.1 and 8.4.2 are partially fulfilled, while the standard criteria 8.4.3 and 8.4.4 are fulfilled overall. Partially fulfilled and fulfilled overall element of accreditation assessment in primary cares are influenced by regulation, commitment of managers in doing activities based on regulations and synchronizing regulations in primary cares with nationally and internationally legislation.

Keywords : primary cares, accreditation, medical records