Analisis Deskriptif Wewenang dan Tanggung Jawab Staf Rekam Medis di Puskesmas Tinggede

Descriptive Analysis of the Authorities and Responsibilities of Medical Records Staff at Tinggede Community Health Center

Abstract

Based on in-depth interviews (n=3) at Tinggede Community Health Center, medical records staff are authorized to carry out administrative tasks for Medical Records and Health Information (MEI) in accordance with Minister of Health Regulation No. 24/2022 (patient registration, input/distribution of electronic medical records (MEI) data, storage, and quality assurance). This authority is limited to data administration (not clinical actions), in line with internal guidelines (equipment use and system evaluation). Based on thematic analysis, MEI management and quality assurance are included within staff responsibilities, with an emphasis on maintaining data confidentiality. Primary responsibilities include patient registration, file management, data input, and routine reporting. Challenges include human resource shortages and MEI infrastructure constraints; interaction across medical teams (doctors, nurses, and administrators) is crucial for data completeness. Recommendations include strengthening SOPs and MEI training, as well as implementing an integrated MEI system (ePuskesmas) for efficiency. Proposed performance indicators include completeness of medical record content, registration processing time, and compliance with data confidentiality. This study is qualitative in nature, so findings are contextual and cannot be generalized. Limitations: small sample (n=3) and subjective data; need for multi-site studies with quantitative methodology or field observations.