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Journal articles on the topic 'Hospital records'
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LumbanTobing, Susi Indah Roslia, Beby Mashito, and Irwan Nasution. "Analisi Kinerja Pegawai di Bagian Rekam Medis Rumah Sakit Umum Haji Medan." Jurnal Ilmiah Administrasi Publik dan Pemerintahan (JIAPP) 1, no. 1 (January 25, 2022): 31–37. http://dx.doi.org/10.31289/jiaap.v1i1.777.
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Management of medical record s in hospitals is to support the achievement of orderly administration in order to achieve the hospitals goals, namely improving the quality of health services that are affective and efficient in hopitals. Therefore, in the organization of medical records in every hospital. The sick must be admitted to the new general issued by the ministry of health and management. Medical records technically created by the hospital. The purpose of this research is to see. Employe performance in the medical records secition of the General Hospita Haji Medan. This research method used with indepth interviews, observation, documentation and data triangulations. Interview informants consist of medical record officers, doctors and nurses. From the research results, several files the medical records is not completely files in by the doctor, this causes the medical record file to the medical record unit.
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EICHENWALD, HEINZ F., and M. Westren. "MISSING HOSPITAL RECORDS." Pediatric Infectious Disease Journal 6, no. 2 (February 1987): 225. http://dx.doi.org/10.1097/00006454-198702000-00025.
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Nicol, A., and J. Sheppard. "Hospital clinical records." BMJ 291, no. 6496 (September 7, 1985): 614–15. http://dx.doi.org/10.1136/bmj.291.6496.614.
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Thompson, D. N. "Wirral hospital records." Journal of the Society of Archivists 7, no. 7 (April 1985): 421–42. http://dx.doi.org/10.1080/00379818509514259.
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Radhali, Radhali, Tariadi Tariadi, H. S. Brahmana, and Eko Hadiyanto Hadiyanto. "Law Enforcement Opens Medical Records through Public Relations Media of Langsa Hospital." SOEPRA 6, no. 2 (December 31, 2020): 10. http://dx.doi.org/10.24167/shk.v6i2.2593.
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ABSTRACT: Medical record is a file that contains records and documents about the patient's identity, examination, treatment, actions and other services that have been provided to patients. This study aims to determine the legal arrangements regarding the medical record, to find out law enforcement against the Public Relations of Langsa Public Hospital publish patient medical records in online media and to find out the obstacles and efforts made in law enforcement against the Public Relations of Langsa Public Hospital that open patient medical records. The method used in this study is normative and empirical juridical. 1) In medicine, it is not permissible for a doctor or employee of a public hospital to open a medical record through the Public Relations media of Langsa Regional Hospital according to Law Number 29 of 2004 Article 51. 2) Law enforcement against someone who opens a medical record at Langsa Regional Hospital is considered ineffective because law enforcement officials in this case are not serious in handling cases that should be prosecuted. 3) Obstacles in law enforcement in Langsa Regional Hospital, namely that there are still overlapping laws by the police so that law enforcement cannot be carried out fairly and the efforts made in law enforcement against Langsa Regional Hospital that open medical records by means of supervision and coordination between leadership and staff in hospitals Langsa.Keywords: Law Enforcement, Medical Records, Media
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Bourgeois, Stacy, and Ulku Yaylacicegi. "Electronic Health Records." International Journal of Healthcare Information Systems and Informatics 5, no. 3 (July 2010): 1–13. http://dx.doi.org/10.4018/jhisi.2010070101.
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Electronic health records (EHRs) have been proposed as a sustainable solution for improving the quality of medical care. This study investigates how EHR use, as implemented and utilized, impacts patient safety and quality performance. Data in this paper include nonfederal acute care hospitals in the state of Texas, and the data sources include the American Hospital Association, the Dallas Fort Worth Hospital Council, and the American Hospital Directory. The authors use partial least squares modeling to assess the relationship between hospital EHR use, patient safety, and quality of care. Patient safety is measured using 11 indicators as identified by the Agency for Healthcare Research and Quality (AHRQ) and quality performance is measured by 11 mortality indicators as related to 2 constructs, that is, conditions and surgical procedures. Results identify positive significant relationships between EHR use, patient safety, and quality of care with respect to procedures. The authors conclude that there is sufficient evidence of the relationship between hospital EHR use and patient safety, and that sufficient evidence exists for the support of EHR use with hospital surgical procedures.
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Anggorowati, Rita, Tiny Rahayu, Muhammad Irfan Nur Arif, Kiki Muhammad Rizki, Adithya W. P. Lucky, Abil Sabila Rosyad, and Andini Zahra Hafizhah. "Inactive medical record management at Bandung Hospital." International journal of health sciences 6, no. 3 (September 30, 2022): 1520–26. http://dx.doi.org/10.53730/ijhs.v6n3.13160.
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The purpose of this study was to examine the management of inactive medical records in a private hospital in Bandung. The research method used is descriptive-analytic. The research subjects were the head of the medical records section and the storage officer. The results of the study were in inactive medical record storage in the form of microfilm and USB as well as computer notebooks. The medical record room does not have room temperature control, humidity control room, and lighting settings. Maintain the cleanliness of the medical record room and inactive medical records. There is no treatment for inactive medical record files, air exchange, and medical record maintenance. Storage of inactive medical records uses a centralized and decentralized system. Requirements for inactive medical record storage rooms for temperature control, storage cabinets, and room humidity do not use regulators, and there is no supervision.
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Szeto, Karen W. H. "New Medical Record System in Queen Elizabeth Hospital, Hong Kong." Health Information Management 24, no. 4 (December 1994): 131–34. http://dx.doi.org/10.1177/183335839402400404.
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During the 1980's, the medical record problems had been identified and it was not until 1991 that Queen Elizabeth Hospital was chosen to be the pilot hospital for the development of a new medical record management system for the Hospital Authority hospitals. The new medical records system was implemented in Queen Elizabeth Hospital in December, 1993. Six month after implementation, a pre-implementation and post-implementation review of the medical record services were conducted to compare the results of the new and old system. The results showed that there were significant improvements in the record retrieval and record integrity in the new system. New medical record services such as the delivery of readmission records to the ward, filing of medical records forms in pre-defined order and filing of loose sheets in the relevant hospital notes are able to facilitate the efficient, effective and complete access to patient information. The support and cooperation of the hospital staff are crucial to the success of the new system. Continuous review and improvement of the new system is essential in order to obtain the best results
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Anggraeni, Devina, and Muhammad Ikhsan. "The Role of Electronic Medical Records as Evidence in Medical Disputes in Hospitals." SOEPRA 5, no. 2 (April 2, 2020): 311. http://dx.doi.org/10.24167/shk.v5i2.2428.
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Medical Record is a file that contains records and other documents such as patient identification, examination, the treatment that has been given to the patient. Based on the Minister of Health No. 269/MENKES/PER /III / 2008 concerning the medical record that there are two types of medical records that conventional medical records and electronic medical records. With the absence of a strong legal basis related to the setting of electronic medical records, but in reality, many hospitals are using electronic medical records which raised the question, how the role of electronic medical records as evidence in the medical dispute that occurred in the hospital ?. This study uses Descriptio with the normative juridical approach. The data used is qualitative. This is done to get an overview of the roles of electronic medical records as evidence in the medical dispute in the hospital. Electronic medical records in the case of medical dispute resolution in the hospital can not be made as evidence in the medical case settlement, because the regulations related to the use of electronic medical records alone do not yet have a clear legal basis.
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Et. al., Ai Rosita,. "Introduction Study Of Business Intelligence Hospital Medical Recording Data." Turkish Journal of Computer and Mathematics Education (TURCOMAT) 12, no. 11 (May 10, 2021): 1043–50. http://dx.doi.org/10.17762/turcomat.v12i11.5994.
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In every health service facility in a hospital, it is obligatory to make medical records made by doctors and health workers related to the services provided by doctors and other health workers. Medical records made, both outpatient medical records and inpatient medical records, are stored in a medical record file storage area (filling).. Phe management of medical records with the standard Medical Record Information Management (MIRM) is to support orderly administration in the context of efforts to improve health services in hospitals which are supported by a medical record management system that is fast, precise, valuable, accountable, and focuses on patients and safety patients in an integrated manner. The purpose of this system plan is to make it easier for management and leaders to get a visual summary of information for decision making.
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Julita, Ema, Saka Suminar, Rusli Rusli, Sulistyani Prabu Aji, Fitria Eka Resti Wijayanti, Eko Prastyo, and Muhammad Syafri. "Management of Inpatient Medical Records at Dr. Tajuddin Chalid Hospital Makassar." International Journal of Health Sciences 1, no. 1 (March 30, 2023): 35–38. http://dx.doi.org/10.59585/ijhs.v1i1.50.
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Hospitals are health care institutions that organize comprehensive individual health services that provide inpatient, outpatient, and emergency services. Therefore, hospitals are expected to be able to carry out good medical recording activities. Since pre-independence Indonesia has carried out medical recording activities, it's just that it has not been implemented properly, in terms of structuring and processing or following the correct information system. One of the supports for improving the quality of the hospital is in its Medical Record activities. Medical records are related to recording, processing data, and reporting information needed for hospital activities. Medical records as patient health records are useful for providing information from various data on activities carried out to patients while patients are undergoing treatment at the hospital. This study aims to determine how the processing of inpatient medical record files at Ujung Pandang Dr. Tajuddin Chalik Hospital. The research conducted used qualitative research methods with a descriptive approach, namely research that describes and describes the inpatient medical record management system at Dr. Tajuddin Chalik General Hospital. The results of this study are the process of processing medical record files consisting of the process of Completeness (Assembling), Coding (Coding), and Storage (Filling). Conclusion Based on the results of research on the Inpatient Medical Record Management System at Dr Tajuddin Chalid Hospital Makassar that for the input component, namely the medical record personnel of Dr Tajuddin Chalid Hospital Makassar still lacks officers so that it is no longer in accordance with the workload. For facilities and infrastructure, there is a shortage of storage shelves and expansion is needed for medical record storage rooms.
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Ramazata, Bayu, Ermi Girsang, and Yolanda Eliza Putri Lubis. "Analysis Of The Effect Of Job Demand Control-Support And Protection Motivation Towards Obedience With Filling In Medical Records At Batubara Hospital In 2021." International Journal of Health and Pharmaceutical (IJHP) 2, no. 3 (July 3, 2022): 531–39. http://dx.doi.org/10.51601/ijhp.v2i3.108.
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A medical record is part of the archive that describes all activities by an agency within a certain period. Hospitals must have medical records as a service standard in the health sector that is useful for improving quality in providing optimal service to patients. The problem that often arises in filling out medical records is that in the process of filling it is incomplete, and the doctor's writing is less specific about the diagnosis. This situation has an impact on internal and external hospitals because the results of data processing are the basis for making hospital internal reports and hospital external reports. This study aims to analyze the effect of job demand control-support and protection motivation on Obedience with filling in inpatient medical record files at Batubara Hospital in 2021. This type of research is analytical quantitative research. The sample size in this study was 105 people. Data analysis used Univariate, Bivariate, and Multivariate. The results showed Job Demand Control-Support inpatient nurses at Batubara Hospital in 2021 were good as many as 94 respondents and 11 respondents were not good, Protection Motivation at Batubara Hospital in 2021 was good as many as 95 and 10 were not good, Obedience in filling out files inpatient medical records at the Batubara Hospital in 2021, which complied with as many as 94 respondents and 11 respondents who did not obey, Job Demand Control-Support affects Obedience with filling out medical record files for hospitalization at Batubara Hospital in 2021, Protection Motivation affects Obedience in filling out files Medical records for hospitalization at Batubara Hospital in 2021. The variable that has the most influence on Obedience with filling in inpatient medical record files at Batubara Hospital in 2021 is the Protection Motivation variable
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Basir, Nur'aina, Budi Hartono, Aldiga Rienarti Abidin, Endang Purnawati Rahayu, and Abdur Rahman Hamid. "ANALYSIS OF MANAGEMENT ELEMENTS AND MEDICAL RECORD PROCESSING SYSTEM AT BHAYANGKARA HOSPITAL PEKANBARU." Indonesian Journal of Public Health 17, no. 3 (November 4, 2022): 462–76. http://dx.doi.org/10.20473/ijph.v17i3.2022.462-476.
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Introduction: Processing of medical records in hospitals is to support the achievement of administrative order in order to achieve the goals of the hospital, namely improving the quality of health services in hospitals. The results of preliminary observations in processing medical record files at Bhayangkara Hospital were that there were several obstacles including the not yet done assembling, indexing and analyzing medical records and delays in returning medical record files. The aim this study was to determine the elements of man, money, methods, materials, machines in the medical record processing system at Bhayangkara Hospital to improve the quality of medical record services at the hospital. Methods: Qualitative Research and informants: This study amounted to eight people. The number of human resources is insufficient and have never attended training. Standard operating procedures have never been socialized and existing policies need improvement. Result: Coding activities are often constrained by doctors' writing and completeness of diagnoses and medical actions. Retrieval activities are often constrained by medical record files that are still in the inpatient room and in the case mix room. Conclusion: Overall from the research results, the implementation of medical record processing is not appropriate and must be regulated according to existing guidelines in order to produce medical records that are accurate, readily available, usable, easy to trace back and have complete information so as to create quality information and it is recommended to use electronic medical records.
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Shaw, Jane. "Keeping the Record: Medical Records in a Small Hospital." Tropical Doctor 28, no. 3 (July 1998): 131–33. http://dx.doi.org/10.1177/004947559802800303.
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Dewi Kisaputri, Noor Yulia, Nanda Aula Rumana, and Puteri Fannya. "Tinjauan Pelaksanaan Retensi Dokumen Rekam Medis di Rumah Sakit Medistra Jakarta Selatan." SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat 2, no. 2 (April 29, 2023): 387–94. http://dx.doi.org/10.55123/sehatmas.v2i2.1754.
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Retention is an activity to reduce medical record documents from storage shelves by moving inactive medical record documents from active file shelves to inactive file shelves by sorting them on storage shelves according to the year of visit. Inactive medical records are medical record documents that have reached 5 years and are never used again because the patient does not visit the hospital for treatment. This research method uses qualitative analysis. Based on observations and interviews at Medistra Hospital. Currently, the South Jakarta Medistra Hospital is carrying out retention of medical records, but it has not been completed due to a lack of medical record personnel, there is no distribution of retention scheduling and the large number of medical records has piled up, making it difficult for officers to carry out retention. Medistra Hospitals already have an active DRM In Retention/ Shrinkage SPO, but there is no special officer in the filling section who is also the distribution executor. Suggestions should the implementation of depreciation and destruction of medical records be carried out routinely and make a division of schedules for officers who will carry out the retention of inactive medical records..
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Wenny, Lili Sudria, Lolytasari, Riyan Adi Putra, Pita Merdeka, Muh Ahlis Ahwan, and Ana Afida. "Information on medical records of covid-19 patients in Indonesia." Record and Library Journal 10, no. 1 (June 22, 2024): 112–25. http://dx.doi.org/10.20473/rlj.v10-i1.2024.112-125.
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Background of the study: This research describes medical record management activities in two government hospitals in Indonesia, namely RSUD Tugurejo Semarang and RSUD Kota South Tangerang. This Hospital became history for the Indonesian people during the COVID-19 era and became a referral hospital for COVID-19 patients. Medical records, as written documents regarding the initial history of a patient's illness, can be trusted in the name of law and become archives with legal and historical value. Therefore, it is necessary to look at how the medical records of COVID-19 patients are recorded and utilized. Purpose: Analyze the use of COVID-19 medical records as a source of health information data in hospitals. Method: This research uses descriptive qualitative methods. Data sources come from observation, interviews, and documentation. Findings: The research results found that medical records at General Hospitals in Indonesia are managed based on life cycle files, following the guidelines issued by the Regulation of the Minister of Health of the Republic of Indonesia Number 24 of 2022 concerning Medical Records. Conclusion: The more organized a hospital's medical record archive is, the more information contained in the medical record will be visible to researchers.
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Rendarti, Rindi. "Faktor-Faktor yang Mempengaruhi Mutu Pelayanan Rekam Medis di Rumah Sakit." Surya Medika: Jurnal Ilmiah Ilmu Keperawatan dan Ilmu Kesehatan Masyarakat 14, no. 2 (November 4, 2019): 59. http://dx.doi.org/10.32504/sm.v14i2.125.
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Background: Medical record units as part of supporting medical services in hospitals have an important role in improving the quality of services in hospitals. The indicator of service quality in hospital is measured by incomplete inpatient medical record files. Based on several studies in various hospitals, the complete of inpatient medical record files is around 70% - 80% from 100%. Based on the preliminary data in action research in PKU Muhammadiyah hospital, there were 60 % incomplete in filling the medical resume from 100% target. There are many things that occurred, one of them are about human resources that is affected by behavior, the implementation of operational standards in filling medical records, punish and reward files. Objective: To review the factors that affect the quality of service in medical record units related to improving the quality of hospital services. Methods: the method of this study used relevant health databases including Scholars by using a combination of terms: hospital service quality indicators, incompleteness in filling medical medical records, quality of medical record services. Results: The result of this study said that there were related between medical record services and quality of hospital services. The quality indicator in the medical record can be able to be measured was the number of incomplete filling in medical record files. Filling of incomplete medical record files has the potential to reduce the overall quality of hospital services Keywords: quality of medical record services, quality of hospital medical services, incomplete medical record filling
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KHOTIMAH, SITI NUR, and SYIFAUL LAILIYAH. "Literature Review: Analysis Of Incompleteness of Filling in Medical Records Data in Hospitals." Hang Tuah Medical Journal 21, no. 2 (May 30, 2024): 293–304. http://dx.doi.org/10.30649/htmj.v21i2.492.
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Background: Analysis of incomplete filling of medical record information is needed to identify incomplete filling of patient cards in hospitals. Health information can be considered complete if the physician has filled in complete patient information within 1 x 24 hours after providing inpatient or outpatient services. Purposes: This study aims to determine incompleteness in filling hospital medical records and determine the factors that influence incomplete patient information in hospitals. Methods: Literature review with a comprehensive strategy via the internet using PRISMA. Literature was searched via Google Scholar with a publication year range of 2018-2023. Results: Several hospitals in Indonesia still have incomplete patient records. The incompleteness of hospital medical records in the study was shown in percentages of 59.48%, 17.40%, 42.4%, 7.66% and 15.7%. Factors of incomplete medical records in terms of 5M (Man, Machine, Method, Material, Money) Conclusions: Incompleteness of medical records is caused by a lack of knowledge, motivation and awareness of medical record managers. Discussion forums are not held in the form of meetings to discuss evaluation and follow-up as well as sanctions for officials who do not provide complete patient information. Lack of social skills when filling out medical records, unsystematic arrangement of medical record forms, and limited availability of funds.
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Dujat, C., R. Haux, P. Schmücker, and A. Winter. "Digital Optical Archiving of Medical Records in Hospital Information Systems – A Practical Approach Towards the Computer-based Patient Record?" Methods of Information in Medicine 34, no. 05 (September 1995): 489–97. http://dx.doi.org/10.1055/s-0038-1634622.
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Abstract:The large number of inpatients and outpatients in university hospitals leads to high costs of medical documentation and to an increasing number of medical documents. Due to legal regulations, these medical records have to be stored for 30 years. This implies spatial, organizational, and economical problems. At present, conventional archiving in hospitals often does not satisfy the need to make medical records available for healthcare professionals in a systematic and timely manner. From 1989 to 1993 a pilot study on “digital optical archiving of medical records” was carried out at Heidelberg University Hospital. The study has shown the feasibility of digital optical archiving in hospitals if done under certain conditions. In 1995, Heidelberg University Hospital adopted a procedure for“ digital optical archiving of medical records”. The digital optical archive will first be filled with the medical records of the department of neurosurgery and the endoscopic and echographic images and reports of the department of internal medicine. It is to be expected that this procedure will gradually lead to an integrated functionality on health-care professional workstations, to a hospital-wide use of an electronic patient record, and to media-independent document management systems. The paper focusses on the potentials of digital optical archiving as an integral part of hospital information systems, and on the requirements for the systematic managements of hospital information systems with respect to digital optical archives.
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Putrikama, Nurhaliza, Deasy Rosmala Dewi, Puteri Fannya, and Nanda Aula Rumana. "Tinjauan Pelaksanaan Controlling (Pengawasan) Sistem Penjajaran Rekam Medis di Rumah Sakit Annisa Cikarang." Sehat Rakyat: Jurnal Kesehatan Masyarakat 1, no. 3 (August 28, 2022): 230–39. http://dx.doi.org/10.54259/sehatrakyat.v1i3.1089.
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Medical records are one of the important files in health care facilities, both in clinics, health centers and hospitals because they contain a patient's medical history. In order to keep these medical records available when needed, supervision is needed. Thus, from the supervision of the implementation of medical records in the filing room of hospital institutions, the process can be known, whether there are deviations or errors and the extent of errors that occur in the process. Research on the implementation of the Controlling (Supervision) medical record alignment system was carried out at the Annisa Cikarang Hospital. This study aims to determine how the supervision of the medical record alignment system at the Annisa Cikarang Hospital. This study uses a qualitative method with informants 1 medical record coordinator, 1 person in charge of filing and 6 officers in the filing room. The results of the research obtained are that there is no SOP for alignment and supervision that has not been carried out using an expedition book. Suggestions for the Annisa Cikarang Hospital are to add procedures in the alignment to be more detailed, and to have an expedition book to make it easier to track medical records.
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Lukitasari, Dian Ayu, Mohammad Zamroni, and Andika Persada Putera. "Hospital Legal Responsibilities for Misuse of Patient Personal Data In Electronic Medical Records." JILPR Journal Indonesia Law and Policy Review 5, no. 1 (October 18, 2023): 60–74. http://dx.doi.org/10.56371/jirpl.v5i1.164.
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The purpose of this study was to analyze the patient's personal data protection law in the electronic medical record and to analyze the legal responsibility of the hospital for the misuse of patient's personal data in the electronic medical record. This research uses normative research methods and uses statutory and conceptual approaches. The issuance of Regulation of the Minister of Health Number 24 of 2022 concerning Medical Records which requires hospitals to maintain electronic medical records no later than December 31, 2022. The transition from conventional medical records to electronic medical records carries the risk of misusing patient personal data. The results of this study conclude that hospitals as personal data controllers and electronic system operators are required to implement Law Number 27 of 2022 concerning Protection of Personal Data in organizing electronic medical records except those specifically regulated by other laws and regulations and hospitals as corporations have legal responsibilities for misuse of patient personal data in electronic medical records, namely administrative liability, civil liability and criminal liability.
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Munthe, Josua Saputra, and Oktaviani Suryati. "Penyebab Ketidaklengkapan Data Diagnosis Pada Rekam Medis Elektronik Terkait Pelaporan(Rl5.3) di Rs St. Elisabeth Medan." SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat 1, no. 4 (October 29, 2022): 710–16. http://dx.doi.org/10.55123/sehatmas.v1i4.988.
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Electronic Medical Record (RME) is a computerized health information system that contains social data and patient medical data, and can be equipped with a decision support system. Electronic Medical Records can help better management of patient health services (Andriani et al., 2017). Santa Elisabeth Hospital Medan in inputting its Electronic Medical Record data already uses a web-based application. Where this web-based application is called Sphaira Mobile Electronic Medical Record. This application is still newly implemented and used in the electronic medical record system at the Santa Elisabeth Hospital Medan. With the transfer from manual medical records to electronic medical records, this has resulted in several problems in filling out patient electronic medical records. The purpose of this study was to determine the cause of the incomplete diagnosis data in electronic medical records related to the reporting of the top 10 inpatients (Rl5.3) at the Santa Elisabeth Hospital, Medan. The type of research used is descriptive and qualitative with observation and interview data collection techniques. Based on the results of interviews with the head of the medical record room at Santa Elisabeth Hospital Medan, he stated that the transition from manual medical records to electronic medical records made hospital employees, especially officers in the medical record room, have to adapt, recognize and learn how to operate the Sphaira Mobile Electronic Medical Record application. Factors Causes of incomplete diagnosis data in electronic health records at Santa Elisabeth Hospital Medan: Man. Methods, machines
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Rahmatiqa, Chamy, Nurul Abdillah, and Fajrilhuda Yuniko. "Factors that cause compliance filling medical records in hospitals." International Journal Of Community Medicine And Public Health 7, no. 10 (September 25, 2020): 4180. http://dx.doi.org/10.18203/2394-6040.ijcmph20204393.
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Hospital recording system guidelines or known as medical records. Failure to fill medical records has an impact on the quality of service and hospital accreditation. The purpose of this study is to see what factors are the cause of non-compliance in filling Medical Records in hospitals throughout Indonesia. Research is a systematic review. The source of this research data comes from the literature obtained through the internet in the form of published research results regarding the causes of the inability of medical record documents in hospitals from all journals that have been published and can be accessed via the internet. Data was collected from 15 April 2020-10 July 2020. The results of the analysis through document review showed that the factors causing non-compliance of filling medical record documents at the High Hospital were human resources which were 66.6%, there was no clear and firm policy of 33.3%, facilities that did not support were 22.2% and limited funds by 11.1%. It is expected that each hospital must have a clear and firm policy in dealing with non-compliance with filling out this medical record document. With a clear and firm policy on the condition of HR unpreparedness, the facilities and financial conditions which will also be regulated in the policy can also be overcome at the same time.
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Triananda, Besse Lizanty, Indahwaty Sidin, Masni Masni, Syahrir A. Pasinringi, Fridawaty Rivai, and Rachmat Latief. "Factors Related to Completeness of Completion and Timeliness of Returning Medical Record Files in Inpatients at Tarakan Hospital." Journal Wetenskap Health 2, no. 2 (August 2, 2021): 62–73. http://dx.doi.org/10.48173/jwh.v2i2.119.
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Medical record is a subsystem of the hospital information system as a whole which has a very important role in improving the quality and service in hospitals. This study aims to analyze the factors related to the completeness of filling and the timeliness of returning medical record files for inpatients at Tarakan Hospital. This type of research is a quantitative study using an observational study with a cross sectional study design. Sampling used total sampling so that the sample in this study were doctors at the Inpatient Installation of Tarakan Hospital, totaling 38 respondents. The results showed that there was a relationship between individual characteristics, organizational characteristics, job characteristics and SOPs with the completeness of filling out medical record files and the timeliness of returning medical record files at Tarakan Hospital. Therefore, it is hoped that the hospital management will continue to improve monitoring and evaluation of the importance of maintaining the quality of medical records, then immediately switch to electronic medical records in order to solve problems that exist in the medical record unit, so that performance improvements and service quality in hospitals can be realized. Tarakan which has an impact on increasing patient satisfaction and loyalty
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Istikomah, Futari Ayu, Feby Erawantini, and Dony Setiawan Hendyca Putra. "Tinjauan Pelepasan Informasi Rekam Medis Berdasarkan Aspek Hukum Keamanan dan Kerahasiaan Rekam Medis untuk Pendidikan di RSUD Sleman." J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan 1, no. 4 (October 15, 2020): 393–99. http://dx.doi.org/10.25047/j-remi.v1i4.2169.
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Regional general hospital of sleman (RSUD) is a hospital located in Sleman Regency with type B education. As a teaching education, Sleman District Hospital often borrows medical records for research (Education) related to the release of medical record information with third parties necessary. Because the character of medical record documents and their contents are confidential, the hospital must guarantee the confidentiality of the contents of the medical record file and legal protection for patients and hospitals. This research was aimed to find out how the release of medical record information based on legal aspects of the security and confidentiality of medical records for education in Sleman Hospital. This type of research is qualitative by collecting data using interviews, observation and documentation. The results of research at the Sleman Hospital in the application of releasing medical record information for educational purposes in the Sleman Hospital are still not by existing regulations related to the unavailability of expedition books or medical record file borrowing books where the book is very important in knowing the existence of medical record files that come out. And a special place for researchers when researching medical record files is not yet available due to limited space in the medical record unit of Sleman District Hospital.
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Sahrana, Oka, Safrizal Safrizal, Arfah Husna, and Dian Fera. "Process Evaluation on Medical Record Reporting and Information Usage Iskandar Muda Hospital Nagan Raya Regency." J-Kesmas: Jurnal Fakultas Kesehatan Masyarakat (The Indonesian Journal of Public Health) 8, no. 2 (October 22, 2021): 29. http://dx.doi.org/10.35308/j-kesmas.v8i2.3669.
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Medical records are all records and documents about the patient's identities, examinations, treatments, actions and other services provided to the patient. Reporting medical records at Iskandar Muda hospital still does not follow standards. This is due to the lack of discipline of officers in filling out medical records, lack of medical records of officers and related health workers, then also influenced by the Hospital Management Information System that does not yet exist. The purpose of the study was to evaluate the reporting of medical records at Sultan Iskandar Muda hospital. This study uses qualitative research. The results showed that Sultan Iskandar Muda Hospital has been processing medical record data. The procedure of making a report that is not appropriate is the completion of resumes and daily census pain hospitalization. While the proper methods are a recapitulation of outpatient visits, making reports of hospital activities and making morbidity reports of inpatients and outpatients. The medical records unit has produced internal and external reports following the guidelines, and middle-level hospital management has fully used medical record information. It can be concluded that in processing medical record data, there are some obstacles. The procedure of making a report is not following the guidelines, and medical record information has been fully utilized.
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Maria Ulfa, Henny. "Peningkatan Pencapaian Nilai Akreditasi Pelayanan Rekam Medis Rumah Sakit Lancang Kuning Pekanbaru Tahun 201." Jurnal Kesehatan Komunitas 2, no. 1 (November 9, 2012): 9–13. http://dx.doi.org/10.25311/keskom.vol2.iss1.35.
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In an effort to improve the quality of care, the hospital must conduct periodic accreditation at least every three years. Standard hospital services meet five basic service activities, namely administration and management, medical services, emergency services, nursing services, medical record services and each hospital has a duty to carry medical records. Preliminary data indicate that the assessment parameter passing grade accreditation service medical records are lacking. The purpose of this study to find out how to increase the value of the parameter Hospital medical service record Lancang Kuning Pekanbaru minimum national standards. This type of research is non standard qualitative data collection methods of observation and in-depth interviews with four informants. Data processing is done by using the technique of triangulation and qualitative analysis. The result showed that the measurement of medical record services performed according to the standard one to seven is only 25.45%. According to the Ministry of Health of the Republic of Indonesia Year 2008 that the value is still below 75%, so the lack of adherence to accreditation standards, therefore, necessary guidelines in accordance with the standard of care medical record up to seven to improve the assessment of medical record services. Lancang Kuning Hospital Pekanbaru after the implementation of the service records of only six standards that could be applied but still not achieve a passing grade of accreditation of medical record services. Caused by power unit medical record does not meet the qualifications of office, the room is not in accordance with the standards of the medical records due to lack of funding from the hospital. Suggested to the hospital for a complete medical record service standards accreditation standards in order to achieve maximum value assessment result therefore hospitals need to create programs and activities, obey the Law of the Republic of Indonesia hospital, and perform periodic accreditation minimum three years if no longer meets the requirements and standards of the hospital license can be revoked.
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Febriarini, Winda, Puteri Fannya, Nanda Aula Rumana, and Noor Yulia. "Tinjauan Lama Waktu Penyediaan Rekam Medis Rawat Jalan Di Rumah Sakit Anna Medika Bekasi." SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat 1, no. 1 (January 15, 2022): 105–13. http://dx.doi.org/10.55123/sehatmas.v1i1.57.
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In the provision of medical record files in hospitals, it is one indicator of patient satisfaction whose time has been determined in accordance with the hospital's minimum service standards, the standard for the time of providing medical record documents for outpatient services is less than or equal to 10 minutes. 10 minutes), while the time for providing inpatient medical record documents is less than or equal to 15 minutes ( 15 minutes). The purpose of the study was to determine the length of time for providing outpatient medical records at Anna Medika Hospital Bekasi. The research method uses a descriptive method with a quantitative approach, the population of outpatient medical record files visiting the hospital, the sample studied is 106 files, through observation, interviews and time measurement records in the timely provision of medical records so that researchers get research results. The results of the study found that 59 (55.66%) medical records were provided on time and 47 (44.34%) medical records were not provided on time. Factors causing the length of time of provision > 10 minutes are errors in storing medical records, full storage shelves, lack of competence of medical record officers. Suggestions can improve the quality of service and the speed of time for providing medical records and holding standard operating procedures (spo) regarding the provision of medical records.
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Astari, Amalia Dwi, and Dina Sonia. "KETIDAKLENGKAPAN DOSCHARGE SUMMARY DAN LAMA PENGEMBALIAN BERKAS REKAM MEDIS DALAM PENINGKATAN MUTU PELAYANAN REKAM MEDIS DI RS X BANDUNG." Jurnal Kesehatan Tambusai 2, no. 3 (September 30, 2021): 63–68. http://dx.doi.org/10.31004/jkt.v2i3.1956.
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Hospitals are a complex institution of health care, because hospital service involves various functions of service, education, and research, and covers a wide range of degrees and kinds of discipline. To enable hospitals to perform professional functions both in the field of medical engineering and in health administration. Hospital maintenance and improvement requires that it have a measure of quality at all levels. The purpose of this study is to know the incompletion review of discharge summary and the long retrieval of medical record files. The method the writer is a quantitative descriptive,50 files of medical records were taken, Analysts used were observation and interview, The subjects in this study are doctors and medical recorders. The results of this study amounted to 79% complete medical records and 21% incomplete files. 75% of files returned on time, and 25% of files returned intime. It seems that hospital x has filled the SOP and the technical instructions are in place. The incompleteness of medical record files greatly affects the quality of hospital health care. It is therefore expected that all officers will be able to perform their duties according to the SOP in the hospital and increase the number for the medical record file. Hospitals can maintain the quality of service for inpatients and outpatients. Word key : discharge summary, hospital, medical record.
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Siahaan, Okta Vealina. "The Relationship Of The Completeness Of Filling In Medical Records With The Quality Of Medical Record Documents In Inpamentation Patients At Grandmed Lubuk Pakam Hospital In 2023." MEDISTRA MEDICAL JOURNAL (MMJ) 1, no. 1 (October 25, 2023): 13–20. http://dx.doi.org/10.35451/mmj.v1i1.1947.
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Medical records are one of the important parts in shaping the implementation of service delivery to patients in hospitals. Completeness of filling out medical records that are accurate, complete, and timely is needed in health services to fulfill the requirements in medical record management. Completeness of filling out medical records with the quality of medical record documents has a very significant role where the higher the completeness of filling out medical records, he higher the quality of medical record documents. This study aims to determine the relationship between the completeness of filling out medical records and the quality of medical records document for inpatients at Grandmed Lubuk Pakam in 2023. The method used in this research is analytic observational with cross sectional research design. The population of thes study were all medical record files of inpatients and sampling using simple random sampling technique as many as 77 files. The study was conducted by checking the observation sheet on the medical record files of hospitalized patients. Data analysis of this study used chi square test with 95% confidence level, (? = 0,05). The results showed that there was a retionship between the completenees of medical record filling and the quality of medical record documents for inpatiens ( p = 0,001 > 0,05 ). It is hoped that hospital will pay more attention to the completeness of filling out medical records on each sheet (form) in order to improve and maintain the quality of hospital services.
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Fajariani, Vinani, Noer Bahry Noor, and Hasnawati Amqam. "Completeness Analysis of Completeness Filling and Time of Returning The Medical Record for Inpatient Patients at Regional General Hospital of Makassar City." Journal of Asian Multicultural Research for Medical and Health Science Study 1, no. 2 (November 11, 2020): 74–83. http://dx.doi.org/10.47616/jamrmhss.v1i2.51.
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At Makassar City Hospital, one of the service indicators that has not been achieved is in incomplete medical record files and medical record files that are returned more than 2x24 hours after service. This study aims to analyze the implementation of the completeness of filling in and the timeliness of returning inpatient medical record files at the Makassar City Hospital. This type of research is mixed methods research. The study design used a cross-sectional approach. The study was conducted in September - October 2020. The results showed that the implementation of completeness of filling in and the timeliness of returning medical record files was still low, this has led to the accumulation of medical record files in the treatment room and delays in returning the files of inpatients to the medical record installation of the City Hospital Makassar. Training on the implementation of medical records has not been comprehensive for all officers at the Makassar City Hospital. The result of the delay in returning the documents is the delay in payment of insurance claims to the hospital. Accumulation of medical records in the treatment room from incomplete medical records and returned to the treatment room. Health workers who forget to fill in complete medical records are only given a sanction in the form of a warning during a meeting with the medical committee. Availability of SOP on filling and returning medical record files at the hospital. The facilities and infrastructure in the implementation of medical records are still insufficient for medical record employees at Makassar City Hospital. It is recommended that the hospital improve the implementation of the completeness and timeliness of returning medical record files, provide incentives or rewards for completing filling in, increase the number of computers and expand the room in the medical record installation, and review the medical record format at Makassar City Hospital
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Reed, Barbara. "Retention of Medical Records at Sydney Hospital." Australian Medical Record Journal 17, no. 4 (December 1987): 6–10. http://dx.doi.org/10.1177/183335838701700404.
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Determining retention policies for the accumulated three and one half kilometres of patient records has become a priority at Sydney Hospital. This has involved a careful consideration of how the retention of a proportion of the total records can be reconciled to the function of the medical record. The techniques of culling, sampling and selection are discussed and an outline of the solution agreed at Sydney Hospital is given.
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Raru, Amida Morina, Siswati, Deasy Rosmala Dewi, and Nanda Aula Rumana. "Analysis of Medical Records Unit Employee Workload During the COVID-19 Pandemic at Mitra Masyarakat Hospital, Mimika, Indonesia." Open Access Indonesian Journal of Medical Reviews 3, no. 4 (July 25, 2023): 447–52. http://dx.doi.org/10.37275/oaijmr.v3i4.325.
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The workload of medical record unit staff at a hospital can vary depending on the size and type of hospital, the number of patients, and the internal policies implemented. Medical record unit employees are responsible for collecting, managing, and storing patient medical records. During the COVID-19 pandemic, the workload of employees in the medical records unit greatly increased because there was a surge in patients due to the pandemic. An increase in the number of patients occurred in all hospitals in Indonesia, including Mitra Masyarakat Hospital, Mimika. This study aimed to describe the workload profile of employees in the medical records unit at Mitra Masyarakat Hospital during the COVID-19 pandemic. This research is descriptive observational research. The location of this research is Mitra Masyarakat Hospital, Mimika, Indonesia. The research was conducted from March to August 2021. Data sources were obtained from interviewing informants, observing and measuring workload in the medical record unit before and during the pandemic. The variables measured in this study were available working time, workload standards, supporting task standards, and supporting task factors, as well as the need for human resources in the Mitra Masyarakat Hospital work unit. The results of the study show that the available working time for medical record unit personnel for each section is 1300 hours/year or 78,000 minutes/year. The need for health human resources for the medical record unit is as many as 20 people. There are 9 medical record officers currently owned by RSMM. Thus it can be concluded the number of employees is less when compared to the workload in the medical record unit at Mitra Masyarakat Hospital.
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Noviliana, Tiara, Siswati, Puteri Fannya, and Wiwik Viatiningsih. "Overview of the Implementation of Medical Record Maintenance at Tarakan Hospital Jakarta in 2021: A Qualitative Study." Open Access Indonesian Journal of Medical Reviews 2, no. 2 (March 11, 2022): 211–16. http://dx.doi.org/10.37275/oaijmr.v2i2.181.
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A medical record is a file that contains notes and documents about patient identity, examination, treatment, actions, and other services that have been provided to patients. Medical records in carrying out maintenance and protection so that medical records are protected from damage and can facilitate the service process. This study discusses the process or activities of maintaining medical records at the Tarakan Hospital, Jakarta. The purpose of this study was to find out what factors could trigger the occurrence of damage or dangers to the medical record unit and to find out the preventive actions taken by the hospital in protecting medical records. This type of research uses a qualitative descriptive method, which describes the implementation of the maintenance of medical record files in the filing room in 2021. The implementation of medical record maintenance by medical record unit officers, it does not follow the SOP that has been set by Tarakan Hospital Jakarta. Constraints in maintaining medical records are seen from biological, chemical, environmental, and security factors. These obstacles are often the factors that cause damage to medical records such as dust, fire/coal on cigarettes, pests/insects, and chemical liquids and maintenance of medical records at the Tarakan Hospital.
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Dharma, I. Gusti Ngurah Aditya, Gede Sukadarmika, and Nyoman Pramaita. "Application of DeLone and McLean Methods to Determine Supporting Factors for the Successful Implementation of Electronic Medical Records at Bali Mandara Eye Hospital." Journal of Applied Science, Engineering, Technology, and Education 4, no. 2 (November 3, 2022): 146–56. http://dx.doi.org/10.35877/454ri.asci1287.
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Information technology in the health sector is currently an important factor in providing health services, especially hospitals. Bali Mandara Eye Hospital has implemented information technology in the registration process and bill issuance from 2015. Electronic Medical Record is a new application that will be implemented in 2021 at Bali Mandara Eye Hospital. Electronic Medical Record is a computerized system for recording patient health history. The implementation of electronic medical records at the Bali Mandara Eye Hospital for 1 year has many problems both in terms of regulations, systems and users. Therefore, the DeLone and McLean methods are used to determine the success rate of the implementation of electronic medical records. In this method, research is conducted on 6 variables, namely System Quality, Information Quality, Service Quality, Intention of Use, User Satisfaction and Net Benefits. From each variable, the researcher combines indicators from other researchers that are more appropriate for measuring electronic medical records. The results obtained that all statements submitted are valid. The success rate of electronic medical records at the Bali Mandara Eye Hospital was obtained at 3.22 or 80.50%. To be able to increase this value, it is recommended to improve the Information Quality, System Quality and User Satisfaction
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Aulia, Az-Zahra Rizky, and Irda Sari. "ANALISIS REKAM MEDIS ELEKTRONIK DALAM MENUNJANG EFEKTIVITAS KERJA DI UNIT REKAM MEDIS DI RUMAH SAKIT HERMINA PASTEUR." INFOKES (Informasi Kesehatan) 7, no. 1 (June 17, 2023): 21–31. http://dx.doi.org/10.56689/infokes.v7i1.1028.
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Electronic medical records are an important achievement of information technology in the world of health and have considerable benefits, one of which is to increase the effectiveness of officer work. The use of electronic medical records at Hermina Pasteur Hospital is still not perfect and there are still several obstacles that can hinder the effectiveness of officers' work. The purpose of this study was to determine the analysis of electronic medical records in supporting work effectiveness in the medical records unit at Hermina Pasteur Hospital Bandung. This research uses descriptive qualitative methods with data collection techniques with observation, interviews, literature studies and questionnaires. The results of this study showed security aspects (91.7%), integrity aspects (82.8%), availability aspects (87.1%), work quality aspects (81.7%), work quantity aspects (79.6%), and work time (86.1%). The suggestions given in this study are: It is necessary to evaluate the use of electronic medical records so that appropriate training can be carried out, carry out routine system maintenance, coordinate with related electronic medical record vendors to update the electronic medical record system, legalize electronic signatures and provide electronic signature tools, hospitals should provide automatic generators for better electricity availability, it is necessary to hold SPO on electronic medical records so that electronic medical records in hospitals can be ensured that they meet the established security, privacy and quality standards.
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Yokl, Robert T. "How to Manage Hospital Records." Hospital Topics 63, no. 1 (February 1985): 18–27. http://dx.doi.org/10.1080/00185868.1985.9948390.
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Nicol, A., and J. Sheppard. "Why keep hospital clinical records?" BMJ 290, no. 6464 (January 26, 1985): 263–64. http://dx.doi.org/10.1136/bmj.290.6464.263.
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Short, C. M. "Symposium on hospital, clinical records." Journal of the Society of Archivists 7, no. 8 (October 1985): 565–67. http://dx.doi.org/10.1080/00379818509514284.
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Valentina and Selvia Sari Ritonga. "Dampak Penumpukan Dokumen Rekam Medis Terhadap Waktu Pengambilan Dokumen Rekam Medis Di RSU Sinar Husni Medan." Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) 6, no. 1 (February 27, 2021): 1–6. http://dx.doi.org/10.52943/jipiki.v6i1.478.
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The filling system is one of the administrators of medical records which is responsible for orderly administration in an effort to improve health services in hospitals. Accumulation of medical record documents will affect of work of officers in the filling section. The purpose of this study is to determine the impact of the bildup of medical records documents on the time of taking medical record documents at Sinar Husni Hospital. This research is a descriptive study with a qualitative approach. The population is all filling officers at the Sinar Husni Hospital and all patient medical records calculated on average in the third quarter of 2020, counted 719 documents. The samples in this study were 2 filling officers at the Sinar Husni Hospital and part of the medical record documents totaling 86 medical record documents that were taken incidentally. The instrument used was an interview guide. The measurement of time to take medical record documents uses a stopwatch. Data were analyzed descriptively. The results showed that the accumulation of medical record documents had an impact on the time to take medical record documents at the Sinar Husni Hospital, because the officers had difficulty carrying out filling activities because the access between shelves was narrower and the documents piled on the floor were not properly aligned, with an average of 10.05 minute. We recommend to add more storage space and shelves so that medical record documents that are stacked on the floor can be moved to the storage racks.
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Aulia, Ni Wayan Riskita, Wiwik Viatiningsih, Nanda Aula Rumana, and Puteri Fannya. "Overview of Completeness of Filling Out Inpatient Discharge Summary Form at General Ahmad Yani Hospital Metro in 2021." Open Access Indonesian Journal of Medical Reviews 2, no. 2 (March 11, 2022): 207–10. http://dx.doi.org/10.37275/oaijmr.v2i2.179.
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Medical records are the property of hospitals that must be maintained because they are useful for patients, doctors, and hospitals. Medical record documents are very important in carrying out the quality of medical services provided by hospitals and their medical as well as accurate evidence in court, doctors, nurses, and other health workers who treat patients are required to complete medical records following applicable regulations. This study aims to describe the completeness of filling out inpatient discharge summary form at General Ahmad Yani Hospital Metro in 2021. This study used a descriptive research method. The research location is the Medical Record Unit of General Ahmad Yani General Hospital Metro Lampung. This research was conducted in October 2021. Of the 100 samples of medical records, the completeness of the inpatient discharge summary form was completed. There are 80% complete and 20% incomplete, where the completeness value of 100% is found in the patient identity filling item, and there are no scribbles. Meanwhile, 20% incompleteness is found in important note items (5%) and authentication (15%). In conclusion, standard operating procedures for completeness of medical records already exist and the implementation of completeness of medical record files has been carried out according to applicable standards, but it can be seen that the steps in the SOP are not detailed and less thorough.
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Tsai, Chih-Yang, Paul Pancoast, Molly Duguid, and Charlton Tsai. "Hospital rounding – EHR's impact." International Journal of Health Care Quality Assurance 27, no. 7 (August 5, 2014): 605–15. http://dx.doi.org/10.1108/ijhcqa-07-2013-0090.
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Purpose – The purpose of this paper is to understand the time spent on various tasks during physician inpatient rounds and to examine the new electronic health records (EHRs) impact on time distribution. Design/methodology/approach – Trained observers shadowed hospital physicians to record times for various tasks before and after EHR implementation. Findings – Electronic records did not improve efficiency. However, task times were redistributed. Physicians spent more time reviewing patient charts using time saved from miscellaneous work. Research limitations/implications – The study focusses solely on work distribution and the changes it underwent. It does not include quality measures either on patient results or physician satisfaction. Practical implications – As EHR provides rich information and easier access to patient records, it motivates physicians to spend more time reviewing patient charts. Hospital administrators seeking immediate returns on EHR investment, therefore, may be disappointed. Originality/value – Unlike previous work, this study was conducted in a non-teaching hospital, providing a task-time comparison without any educational and team factor influence. The result serves as a benchmark for many community hospital managers seeking to address the same issue.
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Ratnawati, Ratnawati. "Analysis The Level of Compliance of Hospital Human Resources in Writing The Status of Inpatient Medical Record Dr Sayidiman Hospital and The Influences Factors." Journal for Quality in Public Health 3, no. 2 (May 12, 2020): 423–33. http://dx.doi.org/10.30994/jqph.v3i2.92.
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The quality of medical records in hospitals also determines the quality of service, completeness of writing Medical Records documents correctly and correctly is very important. The purpose of this study was to analyze the level of compliance of hospital human resources in writing the status of the inpatient Medical Record Dr. Sayidiman Magetan Regional Hospital and the factors that influence it. The design of this study was an observational quantitative study with a cross section approach with the focus of the research directed to be analyzing the level of compliance of hospital human resources in writing the status of the inpatient Medical Record Dr Sayidiman Magetan Regional Hospital and the factors that influenced it with a sample of 192 respondents taken with the Simple Random Sampling technique. The findings found that most of the respondents have high motivation that is 144 respondents (75%). Most of the respondents care to write in the medical record that is 160 respondents (83.3%). Most of the respondents have a high appreciation of 136 respondents (70.8%). Most of the respondents did not comply doing medical record writing of 107 respondents (55.7%). Based on the Linear Regression analysis the motivation variable on compliance p-value 0.015 <0.05, the variable concern for compliance p-value 0.025 <0.05 then H0 is rejected so there is the influence of motivation and concern for compliance with medical record writing by health professionals in Regional General Hospital Dr. Sayidiman Magetan. Linear regression variable rewards for compliance shows that the p-value of 0.665> 0.05 then H0 is accepted so it is concluded that there is no effect of rewards on compliance with writing medical records by health professionals at the Dr Sayidiman Magetan Regional General Hospital. It is expected that respondents can comply to fill out medical records so that the delivery of care to passion can be well integrated
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Swari, Selvia Juwita, Cindy Kurnia Ressa Fransiska, Demiawan Rachmatta Putro Mudiono, Erna Selviyanti, Gamasiano Alfiansyah, and Maya Weka Santi. "Analysis of Causes of Inpatient Medical Records Delayed Retrieval at Muna Anggita Hospital Bojonegoro, Indonesia." JMMR (Jurnal Medicoeticolegal dan Manajemen Rumah Sakit) 12, no. 3 (December 6, 2023): 324–40. http://dx.doi.org/10.18196/jmmr.v12i3.89.
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The delayed retrieval (return) of medical records at Muna Anggita Hospital Bojonegoro in January-May 2022 hindered the data process, reporting, and BPJS claim submissions. It also impeded services when patients underwent health check-ups and affected the quality of hospitals and patient satisfaction. This study aims to analyze the factors causing the tardy return of inpatient medical records based on Lawrence Green's behavior theory, which includes predisposing, enabling, and reinforcing factors. This qualitative study collected data through interviews, observations, documentation, USG (Urgency Seriousness and Growth), and brainstorming. The research subjects include one medical record head, two assembling officers, and four inpatient ward heads. The results indicated that predisposing factors included the lack of knowledge of ward heads and their attitude (behavior) towards extending the return time of medical records. These predisposing factors can occur due to the lack of supporting facilities. Also, motivating external factors such as rewards or reprimands from ward heads and minimal socialization of standard operating procedures (SOPs) regarding borrowing and return of medical records also contribute to the delay. Behavioral factors refer to the ward heads' lack of compliance and discipline in returning medical records. Muna Anggita Hospital should conduct SOP socialization every three months and regularly provide supporting facilities. The ward heads should also set an example regarding medical record return punctuality. The subsequent researchers are encouraged to formulate a strategic plan to reduce the delays in returning inpatient medical records at Muna Anggita Hospital in Bojonegoro.
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Mamani Macedo, Nestor Adolfo, Oswaldo Moisés Canchumani Grillo, Silverio Bustos Díaz, Luzmila Elisa Pró Concepción, Jaime Pariona Quispe, and Rolando Mendivil Zapata. "Análisis del dominio desde una perspectiva ontológica: El caso de la Historia Clínica General Peruana." Revista de investigación de Sistemas e Informática 6, no. 1 (December 30, 2009): 47–56. http://dx.doi.org/10.15381/risi.v6i1.6000.
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This paper presents the initial results of the research project “Automated Medical Records with Applications to Extrahepatic Obstructive Jaundice,” which has the support of the Science and Technology Program - PCyT - Fund for Innovation, Science and Technology - FINCyT . The project arises from the evidence that the majority of public hospitals only have management systems of medical records in paper, which requires that a patient has a health record in every hospital where he attends. In that sense, the purpose of this project is to develop a socio-technological proposal to manage electronic health records, making possible interoperability between different peruvian hospitals.
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Tri Ariani, Tri, Eny Retna Ambarwati, and Wiyadi Wiyadi. "Evaluasi Sistem Pengelolaan Rekam Medis Pasien Rawat Inap Study Kualitatif di RSKIA UMI KHASANAH." Jurnal Ilmu Kebidanan (Journal of Midwivery Science) 9, no. 3 (January 29, 2022): 131–38. http://dx.doi.org/10.36307/jik.v9i3.122.
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ABSTRACTGood management of medical records to support hospital services and useful if the information contained therein is complete and accurate. Medical record data is needed in the process of recording and reporting routine hospitals. The purpose of this research is to treat and manage medical records of inpatients at RSKIA Umi Khasanah Bantul. descriptive research with a qualitative approach. Research subjects Director, medical record personnel, midwives and doctors. Data collection using in-depth interview techniques supported by documentation. Data analysis technique with reduction, presentation, conclusion. The results of the patient's medical research using a manual system. Medical records are more than 2 x 24 hours because the medical record documents are not completely filled, the storage space is not sufficient, the SOP for medical records is not complete, the length of providing medical records according to the law is <15 minutes, supervision medical records seen from the assessment indicators. The problem is that there is still a lack of medical record personnel, insufficient infrastructure.Keywords: Evaluation, Management, Medical Records
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Ernaman Putri, Riza Suci, Widya Putri, and Siti Wulandari. "SOSIALISASI PELAKSANAAN RETENSI DAN PEMUSNAHAN REKAM MEDIS DI RS AWAL BROS BATAM." PRIMA PORTAL RISET DAN INOVASI PENGABDIAN MASYARAKAT 2, no. 2 (April 4, 2023): 180–86. http://dx.doi.org/10.55047/prima.v2i2.671.
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Medical record is a file that contains notes or documents regarding patient identity, examinations, actions, and other services that have been provided to patients. Medical records are said to be of good quality if they are accurate, complete, reliable, valid and timely to return. According to the standard procedure (Protap) regarding the return of medical records no later than 2x24 hours after the patient returns home or after the patient leaves the hospital. This is intended so that medical record officers are ready to provide patient medical records if needed at any time. Awal Bros Batam Hospital has carried out retentions starting from 2016 onwards with vendors. Currently Awal Bros Batam Hospital already has 1 tool for destroying medical record files in the medical record unit. However, the lack of human resources in the medical record unit makes employees in medical records still doing work, not just one job but they do more than one job.
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Sonia, Gina, Lily Widjaja, Deasy Rosmala Dewi, and Puteri Fannya. "Ketersediaan Rekam Medis di Rumah Sakit Islam Jakarta Sukapura." SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat 1, no. 2 (April 27, 2022): 157–64. http://dx.doi.org/10.55123/sehatmas.v1i2.110.
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The medical record is an administration system that records all diagnoses and actions followed by the storage of medical records. Medical record retrieval is an important part to support the effectiveness of services in providing medical records for patients who return to the hospital. This research method uses quantitative descriptive and data collection techniques by observation, interviews and literature study. Based on the results of the research, the filing officer of the Islamic Hospital of Jakarta Sukapura often faced problems during retrieval, the results of the study found that 17 (3.4%) medical records were not found and 26 (5.2%) medical records were misplaced. Factors inhibiting the implementation of medical record retrieval include man factors such as the educational background of officers and the habitual factor of officers who do not use tracers when carrying out medical record retrieval that is not in accordance with SPO at the Islamic Hospital of Jakarta Sukapura. The money factor does not affect the implementation of medical record retrieval. The machine factor is the SMART system for medical record data entry that comes off the shelf. The method factor is that the standard operating procedure for retrieval of medical records is not fully appropriate. The material factor is the absence of loan receipts.
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De Lima, Émilin Dreher, Carine Raquel Blatt, and Rita Catalina Aquino Caregnato. "EDUCATIONAL TUTORIALS ON THE HOSPITAL PHARMACIST'S RECORD IN THE PATIENT'S MEDICAL RECORDS." Revista Contexto & Saúde 21, no. 44 (December 23, 2021): 32–40. http://dx.doi.org/10.21527/2176-7114.2021.44.12012.
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To document the care on the patient is a necessary skill to the pharmacist. The goal of the study is to prepare educational tutorials related to the registration of Clinical Pharmacy activities in the medical record. It is a technological production carried out in two stages: quantitative cross-sectional study and preparation of educational tutorial videos. Data collection occurred through an online survey of pharmacists active in Brazilian hospitals and Pharmacy professors. The preparation of the educational tutorial videos followed the ADDIE model. 47 professors participated in the research, 100% consider the theme important; and 80% believe that the undergraduate program does not prepare the student for the recording in the medical records. Among the 248 participating pharmacists: only 9% received guidance on the subject during undergraduate course; and less than 40% felt able to record clinical activities in medical records. Three tutorial videos on the recording of the pharmacist's in the medical records were made. The research indicated a need to update the knowledge of Brazilian pharmacists related to the theme record in medical records in services and teaching. The three tutorial videos on the registration of the pharmacist in the medical records were elaborated to disseminate knowledge to pharmacists.
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Wardhana, Erdianto Setya, Erwid Fatchur Rahman, Hayyu Failasufa, and Muhammad Dian Firdausy. "Evaluation of Electronic Dental Medical Records at Sultan Agung Islamic Dental Hospital: Compliance with Indonesian Laws and Regulations." International Journal of Medical Science and Dental Health 10, no. 06 (June 27, 2024): 89–97. http://dx.doi.org/10.55640/ijmsdh-10-06-08.
Full textAbstract:
Background: Dental electronic medical records have already been used in many dental care services in Indonesia. Yet, the actual definitions and constitution that regulate this dental electronic medical record are still in debate. Therefore, this study aims to analyze the use of dental electronic medical records in Sultan Agung Dental Hospital Semarang based on the constitution in Indonesia. Method: Our study used a cross-sectional analysis with an observational description of the component and security of the dental electronic medical record in Sultan Agung Islamic Dental Hospital Semarang. Results: Dental electronic medical record in Sultan Agung Islamic Dental Hospital didn’t complete the odontogram teeth component. The software used in the dental electronic medical record didn’t have a tool to write specific symbols and color signs on the odontogram teeth component. Conclusion: The complete format and the security of dental electronic medical records in Sultan Agung Islamic Dental Hospital Semarang have not aligned with the Indonesian constitution and regulations.