Tujuan: Mengetahui faktor-faktor yang berhubungan dengan mutu rekam medis pasien rawat inap di RSMTP Jakarta Selatan. Metode: Penelitian ini menggunakan studi deskriptif observasional dengan pendekatan kualitatif dan kuantitatif yang menggunakan analisis sistem input-process-output. Subjek penelitian ini adalah kasubid penunjang medis, kepala unit RM, kepala ruang rawat inap, petugas RM, dokter, perawat pelaksana, dan petugas admisi, sedangkan objek penelitian adalah berkas RM rawat inap pada Bulan Mei 2022 sebanyak 103 sampel.
Hasil: Komponen output berupa persentase RM rawat inap bermutu baik sebesar 33% yang terdiri dari kelengkapan isi sebesar 34%, ketepatan waktu pengembalian sebesar 100%, dan pemenuhan persyaratan hukum sebesar 69,9%. Kendala pada komponen input antara lain ketersediaan petugas RM yang sesuai kompetensi masih belum mencukupi, belum tersedianya pelatihan pengisian RM, sosialisasi kebijakan kepada profesional pemberi asuhan (PPA) yang masih bersifat segmented, perakitan formulir yang belum konsisten, dan belum tersedianya SOP pengisian RM sebelumnya yang dibutuhkan sebagai acuan PPA dalam melakukan pengisian RM, kebijakan reward dan punishment belum resmi diberlakukan, anggaran dana untuk pelatihan PPA terkait pengisian RM masih belum tersedia, tidak tersedianya insentif untuk PPA dan petugas RM, dan beberapa sarana prasarana di URM kurang memadai. Selain itu, dari segi process terdapat beberapa kendala dari proses pendaftaran yang mengakibatkan pengisian identitas pasien menjadi tidak lengkap. Pelaksanaan pengisian RM yang kurang baik dikarenakan SOP yang masih belum tersedia dan peran PPA dalam mengisi dokumen RM yang belum baik. Proses pengembalian RM sudah dilakukan secara cukup disiplin dalam waktu 1x24 jam. Kegiatan analisis isi dan pemanfaatannya belum dilaksanakan secara berkala, serta pemantauan dan evaluasi pengisian RM yang belum berjalan dengan baik. Belum terbentuknya komite rekam medis sehingga peran audit rekam medis belum berjalan dengan baik. Kesimpulan: Masih rendahnya mutu RM rawat inap di RSMTP berhubungan dengan beberapa faktor yang masih belum terpenuhi dari faktor SDM sendiri maupun faktor-faktor lainnya yang masih mengalami beberapa kendala, serta beberapa proses terkait mutu rekam medis belum berjalan dengan baik. Saran: Perlu adanya pembuatan beberapa kebijakan seperti pengadaan insentif dan kebijakan reward dan punishment. Selain itu, beberapa aspek lain perlu diperhatikan yaitu anggaran untuk pelatihan, pembentukan panitia RM, sosialisasi SOP secara menyeluruh, pemanfaatan analisis isi sebagai acuan evaluasi mutu RM dan kinerja PPA, serta peran PPA dalam memberikan fokus kepada beberapa item rekam medis sehingga seluruh indikator mutu dapat tercapai.

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Background: Medical record (MR) service, especially for inpatients, is one aspect of quality assessment which is reflected in the quality of MR documents carried out by RM filling officers and their management in the medical record unit (MRU). Based on minimum service standards in hospitals, there are four indicators of MR quality targets, namely completeness of contents, accuracy of contents, timeliness of returns, and compliance with legal requirements. The results of the monthly MRU evaluation of the Muhammadiyah Taman Puring Hospital (RSMTP), show the percentage of completeness medical resumes on November 2021 which is still low (32.10%). In addition, the implementation of data recapitulation and analysis of the contents of the MR has just been carried out so that there is no comprehensive evaluation process for the completeness of the MR. Objective: To determine the factors related to the quality of medical records of inpatients at RSMTP South Jakarta. Methods: This study uses a descriptive observational study with a qualitative and quantitative approach that requires an input-process-output system analysis. The subjects of this study were the sub-division of medical support, the head of the MR unit, the head of the inpatient room, the MR officer, doctors, nurses, and admissions officers, while the object of the study was the inpatient MR files in May 2022 as many as 103 samples. Results: The output component in the form of the percentage of good quality inpatient MR is 33% consisting of completeness of contents (34%), timeliness of return (100%), and compliance with legal requirements (69.9%). Constraints on the input component include the availability of competent MR officers who are still not sufficient, the unavailability of MR filling training, policy socialization to professional care providers (PCP) which is still segmented, inconsistent form assembly, and the unavailability of the previous RM filling SOP that needed as a reference for PCP in filling out MRs, reward and punishment policies have not been officially implemented, budget funds for PCP training related to filling MRs are still not available, incentives are not available for PCP and MR officers, and some infrastructure facilities at MRU are inadequate. In addition, in terms of the process, there were several obstacles in the registration process which resulted in incomplete filling of the patient's identity. The implementation of filling out the MR is below standard because the SOP is still not available and the role of the PCP in filling out the MR document still not showing their best effort. The MR refund process has been carried out in a fairly disciplined manner within 1x24 hours. Content analysis and utilization activities have not been carried out on a regular basis, as well as monitoring and evaluation of MR filling that has not been going well. The medical record committee has not yet been formed so that the role of the medical record audit has not gone well. Conclusion: The low quality of inpatient MR at RSMTP is related to several factors that have not been fulfilled, from the human resources factor itself and other factors who are still experiencing some problems, as well as several processes related to the quality of medical records that have not gone well. Suggestion: It is necessary to make several policies such as the provision of incentives and reward and punishment policies. In addition, several other aspects need to be considered, such as the budget for training, the formation of an MR committee, comprehensive socialization of SOPs, the use of content analysis as a reference for evaluating MR quality and PCP performance, and the role of PCP in providing focus to several medical record items so that all quality indicators can be achieved.