Lessons from a Dinosaur: Mediating is Research Through an Analysis of the Medical Record

2019 ◽

Vol 14 (1) ◽

pp. 7

Author(s):

Cinthia Mutiara Hapsari ◽

Ary Subiyantoro

Keyword(s):

Health Services ◽

Health Information ◽

Medical Record ◽

Electronic Medical Record ◽

Data Storage ◽

Safety Data ◽

Patient Medical Record ◽

Is Research

Backgroud: A hospital was a part of a whole system health services which aims to carry out health services, these services through the effort to healing patients .In order to to support these health services then required health information of the members of the data that is neither of the patients medical record. Objective:to determine the usage of electronic medical record in hospital. Method:The method used in this research was normative yuridis. The data presented in the form of the patient medical record manually and electronic medical record , and the data it is very important to the hospital .Because of that , needed there is research on how the comparison between medical record manuals by electronic medical record if record of profit and weaknesses and how in terms of safety data storage electronic medical record compared to manual medical record and assess whether electronic medical record can be used as an instrument the evidence in the investigation in the provision of health services related to not repeat this research with methods of juridical normative. Result: This research gained an electronic medical record. The results showed that has certain excellence that more so than with manual medical .Medical can also record it becomes a tool the evidence in the investigation in a similar way manual medical record. Conclusion: The conclusion of this research was the usage of electronic medical record is more savety, accurate and effective in hospital

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More Than Just a Medical Record

ASHA Leader ◽

10.1044/leader.bgj2.18082013.12 ◽

2013 ◽

Vol 18 (8) ◽

pp. 12-12 ◽

Cited By ~ 1

Keyword(s):

Medical Record

More Than Just a Medical Record

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Coding for Evaluation and Treatment

Perspectives on Voice and Voice Disorders ◽

10.1044/vvd18.1.9 ◽

2008 ◽

Vol 18 (1) ◽

pp. 9-20 ◽

Cited By ~ 1

Author(s):

Mark Kander ◽

Steve White

Keyword(s):

Medical Record ◽

Treatment Session ◽

Accurate Diagnosis ◽

Third Party ◽

Speech Language Pathologists ◽

Adequate Information ◽

Diagnosis Codes ◽

Coding Rules ◽

Procedure Codes ◽

The Web

Abstract This article explains the development and use of ICD-9-CM diagnosis codes, CPT procedure codes, and HCPCS supply/device codes. Examples of appropriate coding combinations, and Coding rules adopted by most third party payers are given. Additionally, references for complete code lists on the Web and a list of voice-related CPT code edits are included. The reader is given adequate information to report an evaluation or treatment session with accurate diagnosis, procedure, and supply/device codes. Speech-language pathologists can accurately code services when given adequate resources and rules and are encouraged to insert relevant codes in the medical record rather than depend on billing personnel to accurately provide this information. Consultation is available from the Division 3 Reimbursement Committee members and from [email protected] .

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