(KTI) IMPLEMENTATION OF RETENTION OF MANUAL MEDICAL RECORD TO ELECTRONIC MEDICAL RECORDS AT PERTAMINA CIREBON HOSPITAL

Technological developments in society have resulted in the transformation of the
digitalization of health services so that medical records need to be maintained
electronically according to the principles of security and confidentiality of data and
information. Medical record retention is an activity of storing and archiving patient
medical records which is very important to ensure the availability of patient medical
record data within the specified time period. Retention of medical records is carried out
to fulfill legal, administrative and clinical data. The aim of this research is to provide an
overview of the implementation of the process of transitioning manual medical record
retention to electronic medical records at Pertamina Cirebon Hospital.
The type of research used is descriptive. This research instrument uses an
observation sheet. This data collection technique is to use observation. The subject of this
research is manual medical record SOPs. The research object was 2 people implementing
the retention transition.
Based on the research results, it was concluded that in implementing the
transition from manual medical record retention to electronic medical records using 5M,
the main obstacle was influenced by human resource factors, namely the limited number
of filing officers in the retention section and the lack of appropriate educational
background. So that retention candidates are facilitated to participate in training
Keywords : Retention, electronic medical records, manual medical records, transition
Bibliography : 20 (2016-2023)