Analysis of Affecting Factors of the Medical Record Service Waiting Time of Outpatient Ambulatory in Sundari Medan Hospital

Analysis of Affecting Factors of the Medical Record Service Waiting Time of Outpatient Ambulatory in Sundari Medan Hospital Lilya Lunanda, Mappeaty Nyorong, Achmad Rifai Student of Master's Program in Public Health Sciences, Helvetia Health Institute Medan, Indonesia Lecturer of Faculty of Public Health, Helvetia Institute of Health Medan, Indonesia *Corresponding Author: Lilya Lunanda Article Info


Introduction
Health is a healthy state, both physically, mentally, spiritually and socially that allows everyone to live productively socially and economically. Healthy is a dream that is expected by all groups of people. The state as a place where people are sheltered has an obligation to facilitate in all efforts to achieve and maintain a healthy state. The Constitution of 1945 Article 28 and Article 34 of the State ensures that every citizen has a prosperous life, a place to live, and is responsible for the provision of health care facilities ( Meutuah & Ishak, 2015).
Health services aim to improve health and prevent disease with the main target is the community, where the scope of health services concerns the interests of the public so that the role of many parties in the health service is quite large (Fitriani, 2017). Quality health services are one of the most important elements in improving the level of public health more optimally (Putri et al., 2018) The hospital itself is an integral part of the overall health care system developed through health development plans. In Law No.44 of 2009 concerning Hospitals, hospitals are health service institutions that provide individual health services in a plenary manner that provides inpatient, outpatient, and emergency services and has functions that require hospitals to take a role in improving national health degrees (Fitriani, 2017). The goal is to make it easier for people to obtain services in the field of health. The rights of patients, hospital workers and those around them must also be protected and properly safeguarded. Providing legality for working people and sick people who are treated and the hospital itself is something that we should not ignore or forget (Chrismanda, 2018).
A new trend in international hospital services today is how to build patient-focused services and provide safer healthcare based on continuous quality improvement. The demands of today's society that hospitals should be able to provide one stop services,meaning thatall health care needs related to patients must be able to be served by the hospital quickly, accurately, quality and affordable, which in the end can provide satisfaction in the results of treatment in accordance with the disease suffered (Dewi et al., 2020).
Hospitals as a means of health services are absolutely needed by all levels of society in an effort to improve the level of health of both individuals and society as a whole. To meet these needs, hospitals are required to provide adequate and satisfactory services. Therefore, hospitals must be able to improve the quality of services, including improving the quality of outpatient services (Dindatia & Junaid, 2017). Outpatient services are one of the functional units in a hospital that handles the reception of patients, both those who will be on the road and who will be treated (Supriadi, 2018).
Outpatient services are now one of the main concerns of hospitals around the world, as the number of outpatients is much larger than inpatients, so outpatients are a major market that is predicted to offset future incomes from inpatients that could improve hospital finances. In addition, in choosing a hospital for hospitalization, the choice of patients usually starts from outpatient services (Farianita, 2016).
Outpatient is the backbone of the health care system because of its role as the gateway to inpatient services and other health services. Outpatient health services are now one of the main concerns of hospitals around the world. This is because of the tendency of the public to seek practical medical care efforts once and on that day also get a complete service (one day care). Therefore, hospital management realizes that establishing a strong position in the outpatient market is important for the continuity of the hospital. Thus, outpatient management must be able to provide quality services in order to maintain existing customers (Hamidiyah, 2016). One form of outpatient services in hospitals is the distribution of medical record files that must be in accordance with the government's set (Sandika, 2018). Supporting components include the field of administration, infrastructure and human resources (Nurfadhilah, 2017). The most important element in providing good and quality health services, one of which is the implementation of documentation in the medical record file. Of course, in order to get good quality, the implementation of this medical record must be done by maintaining quality and maintaining it properly and in accordance with the prevailing standards (Chrismanda, 2018).

Medical records according to Permenkes Number 55
Year 2013, is a file containing records and documents about the identity of patients, examinations, treatment, actions and other services to patients in health care facilities. Medical records contain written information about patient health care that can be used in processing, facility planning, health services, and also used for media research in health care statistics activities .
The distribution of good medical record files is the rapid, precise and efficient distribution of medical record files. If the time in the distribution of medical records is long, it will hinder the health services that will be provided by the doctor to the patient, because the doctor can not provide health services to patients without the patient's medical record file. Distribution of medical record files should be able to support health services, especially quality outpatient services (Wiguna & Sidauruk, 2017). The purpose of this study was to determine how the factors that influence the waiting time for outpatient medical record services at Sundari Hospital, Medan.

Methods
This type of research uses my researchalitatif deskriptif analytics. Descriptive qualitative research inthe form of research by method or approach of casetudy. This study focuses intensively on one particular object that studies it as a case. Case study data can be obtained from all parties concerned, in other words in this study collected from various sources. Descriptivequasi-litative research is used to describe, explain, or summarize various conditions, situations, phenomena, or various research variables according to the events as they can be photographed, interviewed, observed, and that can be expressed through documentary materials (Susila, 2015) Informants are one of the important sources of data in this study. Determination of data sources in interviewees is done purposively, i.e. selected with certain considerations and objectives (Sugiyono, 2014) The informasn is as many as 7 people, namely registration officers 4 people, outpatients 3 people.

Overview of Research Informants
Informants in this study amounted to 7 people, 4 officers of the registrirtation section, namely informants 1 to informants 4, 3 patients who made outpatient visits, namely informants 5 to informants 7. In the table below described the characteristics of research informants, as follows: Based on the table above informant Age > 20 years and the education of medical personnel is Diploma and S1, while the informant education patients graduated high school and housewives and traders work.

Standard Operational Procedure (SOP) on Waiting Timefor Outpatient Medical Record Services
The result of the interview was obtained that the registration officer did notdirectly askthe patient who will be treated to takea ticket, but the patient is welcome and taken directly by another officer, namely the security guard on duty at the hospital. From the results of the interview obtained the results that the registration officer always directs the patient to bring a registration ticket to the place of admission of outpatients, then the patient will also be directed to wait until the patient's queue number is called. From the results of the interview, it is obtained that the officer always records on the register book of the patient's name, medical record number, identity and social data of the patient. For patient complaints are not always recorded, only in a few cases that are recorded according to the needs. The results of the interview can be known that the registration officer always asks the patient to show his ticket and medical card. From the results of in-depth interviews obtained information that the patient's polyclinic card is taken by nurses and nurses also who send to the intended polyclinic in accordance with the patient's complaint.

Human Resources on Waiting Time for Outpatient Medical Record Services
The results of the interview were obtained that the background of the last education of the outpatient admission registration officer varies. 1 person with the last education D3 Medical record, 1 person with the last education S1 Education, 1 person with the last education S1 Manajeman and 1 person with the last education S1 Accounting. The results of the interview obtained information that from 4 informants medical records officers only 1 person who has a Registration Certificate (STR), because the informant with a background in medical record education. As for the other 3 informants do not have a Registration Certificate (STR) because the educational background is not from the field of health. Interviews conducted on informants obtained information that of the 4 informants who have a Work License (SIK) only 2 informants namely informants 1 and 2, while for informants 3 and 4 do not have a Work License (SIK).

Facilities for Waiting Time for Outpatient Medical Record Services
The results of interviews conducted on informants are obtained information that tickets are always available at the patient reception counter, because tickets are needed in the flow of patients treating the road at RSU Sundari. The results of the interview conducted on the informant obtained information that there is a telephone that is always active for registration officers in the outpatient admissions section at Sundari Hospital, but if they have a need on the officer who is on the 2nd floor they contact with a mobile phone, because on the 2nd floor there is no telephone.

Technology on Waiting Time for Outpatient Medical Record Services
The results of the interview were obtained that the obstacles in running hospital management information so far is the network, then SIMRS has not bridgingsystem with bpjs vclaim health, so the pengentryan is done separately and takes longer.

A patient's Administration to the Waiting Time of Outpatient Medical Record Service
The results of the interview were obtained that the three informants, namely patients who are on road treatment at Sundari Hospital carrying original identity cards jkn participants (National Health Insurance) which is used as a requirement for outpatient services.
Interview with the informant regarding the patient carrying the Original Letter of referral. The results of the interview were obtained that the three informants, namely patients who were on street medicine at Sundari Hospital brought real letter referral which was used as a requirement for outpatient services. In addition, there are other requirements that must be brought by patients who want to take street medicine in Sundari Hospital including a photocopy of KTP, photocopy of BPJS card, medical letter and DPJP.

Waiting for Outpatient Medical Record Service
The results of the interview found that there is a difference between patients who register manually and online. For those who register online the process is faster than registering manually. The researchers found that the waiting time required for informant 5 who signed up online was approximately 10 minutes 16 seconds minutes, informant 6 who signed up manually 32 minutes 22 seconds and informant 7 who signed up manually 1 hour 48 minutes 14 seconds.

Standard Operational Procedure (SOP) on Waiting Time for Outpatient Medical Record Services
Standard Operational Procedure (SOP) is a device of instruction / steps that are standardized to complete a routine work process. SOP provides the right and best steps to carry out various activities, functions and help reduce errors and services below standard with measures that have been tested and approved in carrying out various activities (Department of Health RI. 2007) Standard Operational Procedure (SOP) that is good and correct is the data or identity of the patient must be filled in as complete as possible in accordance with the filling of outpatient data to facilitate the work of officers at the place of registration of outpatients . Some hospitals use a "pneumatic tube" which is a medical pressure pipe that can deliver rapid medical records to various parts (Kristina et al., 2015).
Based on the results of the study, existing theories and related studies, researchers are aware that the Standard of Operational Procedures (SOP) for the registration of outpatient services in Sundari Hospital has been applied, only it has not been done perfectly, such as recording incomplete patient data that is related to the complaints of patients who will be on the road. Complaints should be re-asked and recorded completely on all patients instead of just some patients according to the needs of the officer. This is done so that there is a real suitability of the patient's complaint with the complaint listed on the referral letter. Then there is information that is not received by patients related to the ticket code / queue number that applies at Sundari Hospital. So that not a few patients are confused and miss the call of the queue number. This is certainly related to the length of waiting time for patients in applying for outpatient services.

Human Resources on Waiting Time for Outpatient Medical Record Services
Based on the results of the study, existing theory and related research, researchers are concerned that human resources in outpatient medical record services at Sundari Hospital have not been fulfilled properly, can be seen from the results of the study that proves that the registration officer who has the last education in accordance with the qualifications of the position held now only 1 person, namely with D3 education medical records, while 3 other officers come from education that is not in line with the work carried out now, for officers who have attended training related to the work carried out now only 2 people. For officers who have an active Registration Certificate only 1 person and officers who have a Work License only 1 person. The existence of education and training that supports can have a connection with the performance of registration officers, good performance of officers will certainly produce effective and efficient services that impact on patient waiting times to get outpatient services.

Facilities for Waiting Time for Outpatient Medical Record Services
Health care facilities in the face of the era of globalization seeks to improve the quality of services offered to the community. This is because the quality of services can be used as a tool to achieve a competitive advantage. Implementation of quality services performed by health care facilities by providing the best service for consumers with the aim of creating patient satisfaction (Dewi, 2015).
The implementation of medical record activities needs to be supported by the presence of material resources that include materials, equipment, and facilities. Materials are forms and cards or the like that have been printed in accordance with the provisions that support the implementation of medical records. Facilities and equipment are everything that supports the ease of implementation of tasks and management of medical records (Soebarto, 2011).
Based on the results of the study, existing theories and related studies, researchers are concerned that the facilities contained in the medical record service of outpatients at Sundari Hospital have not been fully fulfilled including the Patient Main Index Card (KIUP) is not available in the outpatient admissions section, office stationery is not fully available for registration officers in the outpatient admissions section and telephones are available but not fully connected to other rooms / units in the hospital. So this can be the cause of waiting times for patients who want to make outpatient visits become longer.

Technology on Waiting Time for Outpatient Medical Record Services
Bridgingsystem is the use of web-based service applications that connect health care systems into one. All of this is intended to be able to improve health services in hospitals or health centers and other health services that receive national health insurance services. The lack of human resources in the information section leads to long queues, this is according to the theory that queues occur when the arrival rate is greater than the service level. Queue size can occur if the capacity on a service system is entered input and reSOPnse on the system is slower than input (Supriadi, 2018). This greatly interferes with the timing of the provision of this medical record (Supriadi, 2018). Good and quality medical record service is reflected in the service that is ramah, fast, and comfortable (Darlis, 2012).
Based on the results ofian research, that the technology in the medical record service of outpatients Sundari Hospital Medan 2020 has not been running well because of obstacles that cause outpatient services are less effective that has not been applied bridgingsystem so that the queue is done separately that takes a long time and some management officers. If bridgingsystem has been applied the queue time can be done shorter and there are still other obstacles such as unstable networks. This can certainly trigger the patient's waiting time to be longer.

A Patient's Administration to the Waiting Time of Outpatient Medical Record Service
Factor causes long waiting time in the section of outpatient medical record service is caused by SIMRS that often experience traffic jams, many patients do not carry medical cards and do not carry insurance cards or insurance requirements (for insurance patients) (Tena, 2017). Patient waiting time in this case to the Medical Record service in Outpatient Registration is one of the important things that will determine the initial image of hospital services and is one of the potential components that cause dissatisfaction Patients who have been treated often certainly already know well the requirements that need to be met for road medicine. On the hospital side it was found that there is still a requirement for patients to bring a photocopy of files such as KTP, JKN card and recommendations DPJP. Whereas according to Permenkes no. 28 of 2014 mentioned that the administration of patients who must be equipped for outpatient services consists only of original identity cards jkn participants (National Health Insurance) and Original Letter of reference. There are still patients who do not carry the requirements completely make the patient have to pacing to complete the requirements that certainly require more time to treat the road.

Conclusion
Standard Operational Procedure (SOP) for the registration of outpatient services in Sundari Hospital has been applied, only it has not been done perfectly, such as recording incomplete patient data related to complaints of patients who will be on the road. Then there is information that is not received by patients related to the ticket code / queue number that applies at Sundari Hospital. Human resources in outpatient medical record services at Sundari Hospital have not been fulfilled properly, the registration officer who has the last education in accordance with the qualifications of the position held now only 1 person, namely with D3 medical record education, while 3 other officers come from education that is not in line with the work carried out now, for officers who have attended training related to the work done now only 2 people. For officers who have an active Registration Certificate only 1 person and officers who have a Work License only 1 person. The facilities contained in the outpatient medical record service at Sundari Hospital have not been fully fulfilled, including the Patient Main Index Card is not available in the outpatient admissions section, office stationery is not fully available for registration officers in the outpatient admissions section and telephones are available but not fully connected to other rooms/units in the hospital. The technology in the medical record service of outpatients of Sundari Hospital Medan 2020 has not been running well because there