ABSTRAKPenelitian ini membahas mengenai proses penciptaan rekam medis di Klinik Terpadu Fakultas Psikologi Universitas Indonesia (KTFP UI). Penelitian ini bertujuan untuk mendeskripsikan penciptaan rekam medis di KTFP UI dengan menggunakan model penciptaan rekod yang dijelaskan oleh Shepherd dan Yeo (2003) yakni identifikasi kebutuhan, proses penciptaan serta pengelolaan rekam medis. Metode yang digunakan adalah pendekatan kualitatif dengan studi kasus. Teknik pengumpulan datanya melalui observasi, wawancara dan analisis dokumen. Hasil dari penelitian ini menunjukkan bahwa rekam medis di KTFP UI tercipta secara alami dan cukup sederhana. Belum ada aturan tertulis tentang penciptaan rekam medis. Penciptaan rekam medis ditujukan sebagai rujukan untuk tindakan lanjutan, sarana memonitor, dan sebagai alat komunikasi antar profesional baik internal maupun lintas instansi. Dalam prosesnya autentisitas dijaga dengan mencantumkan nama psikolog, klien serta waktu pelayanan. Pada tahap penyimpanan rekam medis belum sesuai kaidah profesional kearsipan sehingga berakibat pada kurang lancarnya penemuan kembali. Yang penting adalah menambah pengetahuan dan pemahaman para arsiparis rekam medis di KTFP UI dengan memberikan pelatihan manajemen kearsipan sehingga penciptaan rekam medis di KTFP UI menjadi lebih baik.
ABSTRACTThis study discusses about the process of creating medical records at the Integrated Clinic Faculty of Psychology, University of Indonesia (KTFP UI). The purpose of this study is to describe the creation of medical records at KTFP UI by using a model of creating records described by Shepherd and Yeo (2003), namely identification of needs, the process of creating, and capturing medical records. The method used is a qualitative approach with case studies. The data collection technique is through observation, interviews and document analysis. The results of this study indicate that medical records at KTFP UI were created naturally and quite simple. There are no written rules regarding the creation of medical records. The creation of medical records is intended as a reference for follow-up actions, means of monitoring, and as a communication tool between professionals both internally and across agencies. In the process, authenticity is maintained by including the name of the psychologist, client and service time. At the stage of storing medical records it is not yet in accordance with the professional rules of archiving so that it results in retrieval difficulties. The important thing is to increase the knowledge and understanding the archivists of medical records at KTFP UI by providing filing management training so that the creation of medical records at KTFP UI becomes better.
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