A provider-interactive medical record system can favorably influence costs and quality of medical care

1990 ◽  
Vol 20 (4) ◽  
pp. 267-279 ◽  
Author(s):  
Kenric W. Hammond ◽  
Robert J. Prather ◽  
Vishvanath V. Date ◽  
Carol A. King
Keyword(s):  
Medical Care ◽  
Medical Record ◽  
Record System ◽  
Medical Record System ◽  
Quality Of Medical Care

scholarly journals Literature Review: Analisis Faktor Penyebab Keterlambatan Pengembalian Rekam Medis di Rumah Sakit

2021 ◽  
Vol 9 (1) ◽  
pp. 21-29
Author(s):  
Alfita Dewi ◽  
Ilma Nuria Sulrieni ◽  
Chamy Rahmatiqa ◽  
Fajrilhuda Yuniko
Keyword(s):  
Literature Review ◽  
Medical Record ◽  
Medical Records ◽  
Research Literature ◽  
Record System ◽  
Medical Record System ◽  
Causes Of Delays ◽  
Process Component ◽  
Method Factors

AbstractThe quality of medical records describes the quality of health services provided. The return of the medical record file starts from the file being in the treatment room until the file is returned to the medical record unit. Incomplete and not immediately filled out medical resumes cause delays in returning medical records. Therefore, the return of the medical record system is quite important in the medical record unit. This study is a literature review, to see the causes of delays in returning medical records at hospitals in Indonesia. Sources of data come from published research literature, with a total of 18 research articles. Data collection was carried out from March to June 2020. The factor causing the delay in returning medical records was the highest due to the input component. From all journals, 100% of the delays in returning medical records were caused by the input component (Man, Money, Materials, Method, Machine) and 33.3% by the process component. Of the input components, 83.3% were caused by Man factors, 77.8% Method factors, 33.3% Materials factors, 27.8% Machine factors, and 5.5% Money factors. Each hospital must have a clear and firm policy in overcoming delays in returning medical records, with clear and firm policies, the causative factors such as Man, Money, Material, Method, Machine can be minimized and the accuracy of returning medical records can be maximized.Keywords: return, incompleteness, medical records, literature, reviewAbstrakMutu rekam medis menggambarkan mutu pelayanan kesehatan yang diselenggarakan. Pengembalian Rekam Medis dimulai dari berkas tersebut berada diruang rawat sampai berkas tersebut kembali ke unit rekam medis. Pengisian resume medis yang tidak lengkap dan tidak segara dilakukan menyebabkan keterlambatan pengembalian rekam medis. Maka dari itu, pengembalian rekam medis sistem yang cukup penting di unit rekam medis. Penelitian ini merupakan literature review, untuk melihat penyebab keterlambatan pengembalian rekam medis di Rumah Sakit di Indonesia. Sumber data berasal dari literatur hasil penelitian yang telah dipublikasikan, dengan jumlah artikel penelitian sebanyak 18 artikel. Pengambilan data dilakukan dari bulan Maret-Juni 2020. Faktor penyebab keterlambatan pengembalian rekam medis tertinggi disebabkan oleh komponen input.  Dari semua jurnal sebanyak 100% keterlambatan pengembalian rekam medis disebabkan oleh komponen input (Man, Money, Materials, Methode, Machine) dan sebanyak 33,3% oleh komponen proses. Dari komponen input tersebut, sebanyak 83,3 % disebabkan oleh faktor Man, 77,8% faktor Methode, 33,3% faktor Materials, 27,8% faktor Machine, dan 5,5% faktor Money. Setiap rumah sakit harus memiki kebijakan yang jelas dan tegas dalam mengatasi keterlambatan Pengembalian Rekam Medis, dengan kebijakan yang jelas dan tegas, faktor penyebab seperti Man, Money, Material, Method, Machine dapat di minimalisir dan ketepatan Pengembalian Rekam Medis dapat dilakukan secara maksimal.Keywords: keterlambatan, pengembalian, rekam medis, literature review 

ANDROID MEDICAL RECORDS APP UNTUK MENYIMPAN CATATAN MEDIS PASIEN PUSKESMAS KECAMATAN PORSEA

2020 ◽  
Vol 3 (2) ◽  
pp. 175-180
Author(s):  
Herman Saputra ◽  
Adi Prijuna Lubis ◽  
Maulana Dwi Sena
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Health Centers ◽  
Record System ◽  
Medical Record System ◽  
Medical Records System ◽  
The Right ◽  
And Storage ◽  
Computerized System

Abstract : Efforts to improve the quality of health services at the Porsea health center make a medical records system to facilitate the administration and storage of data properly, Porsea health centers still use medical records or forms manually. To make it easy for patients to have a continuous medical history quickly discovered. One of the preparations is to find the right application to be used as a manual medical record system that is digitalized. A simple and easy-to-use medical record system that makes it easy for puskesmas to do patient medical records is the Android Medical Records App Application system, with this application what is expected by the puskesmas can increase the knowledge of Porsea puskesmas employees to use the medical record application, and increase the use of the computerized system, and it is also easy for people who seek treatment to be able to save their medical record data and can be seen traces of their existing medical history.Keywords: android; medical records Abstrak: Upaya meningkatakan mutu pelayanan kesehatan puskemas porsea membuat sistem catatan medis untuk mempermudah administrasi dan penyimpanan data dengan baik, puskesmas porsea masih menggunakan catatan medis atau formulir secara manual. Untuk mempermudah agar riwayat kesehatan pasien berkesinambungan dengan cepat  ditemukan. Salah satu persiapan yang dilakukan adalah mencari aplikasi yang tepat untuk digunakan menjadi sistem rekam medis yang manual menjadi digitalisasi. Sistem rekam medis yang simpel dan mudah digunakan dalam memudahkan pihak puskesmas untuk melakukan pencatatan medis pasien adalah sistem Aplikasi Android Medical Records App, dengan adanya aplikasi ini maka apa yang diharapkan pihak puskesmas dapat Meningkatkan pengetahuan pegawai puskesmas porsea untuk menggunakan aplikasi rekam medis, dan meningkatkan penggunaan sistem terkomputerisasi, dan juga mempermudah masyarakat yang berobat untuk bisa di simpan data catatan medisnya dan dapat dilihat jejak riwayat kesehatannya yang sudah ada. Kata Kunci: android; rekam medis

Impact of Wireless Electronic Medical Record System on the Quality of Patient Documentation by Emergency Field Responders during a Disaster Mass-Casualty Exercise

2011 ◽  
Vol 26 (4) ◽  
pp. 268-275 ◽  
Author(s):  
Theodore C. Chan ◽  
William G. Griswold ◽  
Colleen Buono ◽  
David Kirsh ◽  
Joachim Lyon ◽  
...  
Keyword(s):  
Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Electronic Medical Record System ◽  
Mass Casualty ◽  
Record System ◽  
Medical Record System ◽  
Patient Documentation ◽  
Field Exercise

AbstractIntroduction: The use of wireless, electronic, medical records and communications in the prehospital and disaster field is increasing.Objective: This study examines the role of wireless, electronic, medical records and communications technologies on the quality of patient documentation by emergency field responders during a mass-casualty exercise.Methods: A controlled, side-to-side comparison of the quality of the field responder patient documentation between responders utilizing National Institutes of Health-funded, wireless, electronic, field, medical record system prototype (“Wireless Internet Information System for medicAl Response to Disasters” or WIISARD) versus those utilizing conventional, paper-based methods during a mass-casualty field exercise. Medical data, including basic victim identification information, acuity status, triage information using Simple Triage and Rapid Treatment (START), decontamination status, and disposition, were collected for simulated patients from all paper and electronic logs used during the exercise. The data were compared for quality of documentation and record completeness comparing WIISARD-enabled field responders and those using conventional paper methods. Statistical analysis was performed with Fisher’s Exact Testing of Proportions with differences and 95% confidence intervals reported.Results: One hundred simulated disaster victim volunteers participated in the exercise, 50 assigned to WIISARD and 50 to the conventional pathway. Of those victims who completed the exercise and were transported to area hospitals, medical documentation of victim START components and triage acuity were significantly better for WIISARD compared to controls (overall acuity was documented for 100% vs 89.5%, respectively, difference = 10.5% [95%CI = 0.5–24.1%]). Similarly, tracking of decontamination status also was higher for the WIISARD group (decontamination status documented for 59.0% vs 0%, respectively, difference = 9.0% [95%CI = 40.9–72.0%]). Documentation of disposition and destination of victims was not different statistically (92.3% vs. 89.5%, respectively, difference = 2.8% [95%CI = -11.3–17.3%]).Conclusions: In a simulated, mass-casualty field exercise, documentation and tracking of victim status including acuity was significantly improved when using a wireless, field electronic medical record system compared to the use of conventional paper methods.

Responsibility for a quality of medical care provided via telemedicine

2018 ◽  
Vol 2018 (1-2) ◽  
pp. 9-15
Author(s):  
Morozov S.P. ◽  
◽  
Vladzymyrskyy A.V. ◽  
Varyushin M.S. ◽  
Aronov A.V. ◽  
...  
Keyword(s):  
Medical Care ◽  
Quality Of Medical Care

METHODOLOGICAL APPROACH TO EVALUATING THE EFFECTIVENESS OF RESOURCE USE BY MEDICAL ORGANIZATIONS

2020 ◽  
Vol 3 (7) ◽  
pp. 62-69
Author(s):  
S. S. BUDARIN ◽  
Keyword(s):  
Medical Care ◽  
Resource Use ◽  
Methodological Approach ◽  
Use Of Resources ◽  
Quality Of Medical Care ◽  
Methodological Approaches ◽  
Performance Audit ◽  
Available Resources

The article reveals methodological approaches to evaluating the effectiveness of the use of resources of medi-cal organizations in order to improve the availability and quality of medical care based on the application of the methodology of performance audit; a methodological approach to the use of individual elements of the efficiency audit methodology for evaluating the performance of medical organizations and the effectiveness of the use of available resources is proposed.

Evaluation of medical care for Diabetic and Hypertensive patients in primary care in Mexico: Observational retrospective study (Preprint)

2020 ◽  
Author(s):  
Agustin Lara-Esqueda ◽  
Sergio A Zaizar-Fregoso ◽  
Violeta M Madrigal-Perez ◽  
Mario Ramirez-Flores ◽  
Daniel A Montes-Galindo ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Medical Care ◽  
Serum Lipids ◽  
Quality Care ◽  
Premature Death ◽  
Current Standard ◽  
Anonymized Data ◽  
Quality Of Medical Care

BACKGROUND Diabetes Mellitus is a worldwide health problem and the leading cause of premature death with increasing prevalence over time. Usually, along with it, Hypertension presents and acts as another risk factor that increases mortality risk. Both diseases impact the country's health while also producing an economic burden for society, causing billions of dollars to be invested in their management. OBJECTIVE The present study evaluated the quality of medical care for patients diagnosed with diabetes mellitus (DM), hypertension (HBP), and both pathologies (DM+HBP) within a public health system in Mexico, according to the official Mexican standard for each pathology. METHODS 45,498 patients were included from 2012 to 2015. All information was taken from the electronic medical records database, exported as anonymized data for research purposes. Each patient record was compared against the standard to test the quality of medical care. RESULTS Glycemia with hypertension goals reached 29.6% in DM+HBP, 48.6% in DM, and 53.2% in HBP. The goals of serum lipids were reached by 3% in DM+HBP, 5% in DM, and 0.2% in HBP. Glycemia, hypertension, and LDL cholesterol reached 0.04%. 15% of patients had an undiagnosed disease of diabetes or hypertension. Clinical follow-up examinations reached 20% for foot examination and clinical eye examination in the whole population. Specialty referral reached 1% in angiology or cardiology in the whole population. CONCLUSIONS Goals for glycemic and hypertension reached 50% in the overall population, while serum lipids, clinical follow-up examinations, and referral to a specialist were deficient. Patients who had both diseases had more consultations, better control for hypertension and lipids, but inferior glycemic control. Overall, quality care for DM and/or HBP has not been met according to the standards. While patients with DM and HBP do not have a current standard to evaluate their own needs.

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