Medical Record Borrowing Control Tools Design: Tracer and Outguide Aqsalsa Setya Sabila1*, Anton Kristijono2, Niko Tesni Saputro3
1 Department of Medical Record and Health Information Poltekkes Kemenkes Semarang, Indonesia
2 Department of Medical Record and Health Information Poltekkes Kemenkes Semarang, Indonesia
3 Department of Midwifery Poltekkes Kemenkes Yogyakarta, Indonesia
Abstract
A tracer is an important tool in controlling the borrowing of medical records. It is put in the bag contained in the outguide, which is a substitute for guidelines for exiting the medical record file. A preliminary study at General Regional Hospital RAA Soewondo Pati found that the tracer was not used, and the outguide had not been used according to its designation. The use of both tools is regulated through the SOP of medical record borrowing. The misfile cases are still high. This study is a qualitative research, aiming to design a tracer and redesign the outguide as a control tool of medical records in the medical record unit to reduce the misfile cases. Data were obtained through observation (non-participant) and interviews. The results of the tracer design and the outguide redesign were tested to see the level of acceptance of officers. Data analysis used the Miles and Huberman model by following some steps including data reduction, data presentation, and conclusion drawing. The results of this study show that the filing clerk did not apply the procedures as set in the SOP. The tracer design includes information about the name of the hospital, the patient^s medical record number, the date and time the tracer was discharged, the patient^s name, the patient^s address, the poly or the intended service and the name of the doctor in charge of services. The outguide redesign is rectangular in landscape orientation with 35.4 cm length, 12 cm width, 0.7 mm thickness- this makes the outguide stand out compared to the length of the map. The outguide redesign uses polypropylene plastic. There is a tracer pocket on the left side of the outguide. Improvements to the SOP for borrowing outpatient medical record files are emphasized on the use of tracers and outguide as guidelines for outpatient medical record files being borrowed. The three respondents gave positive feedback to the tracer design and outguide redesign.
Keywords: medical record borrowing- design- tracer- outguide
