Management of medical record in installation of inpatient Regional Public Hospital Batara Guru Belopa

2020 ◽  
Vol 30 ◽  
pp. 481-483
Author(s):  
Musriati ◽  
Indar ◽  
Muhammad Tahir Abdullah ◽  
Rahman Kadir
Keyword(s):  
Medical Record ◽  
Public Hospital

scholarly journals Upaya Pencegahan Perbedaan Diagnosis Klinis Dan Diagnosis Asuransi Dengan Diberlakukan Program Jaminan Kesehatan Nasional (JKN) Dalam Pelayanan Bpjs Kesehatan Studi Di Rsud Kota Semarang

2016 ◽  
Vol 4 (2) ◽  
pp. 84-90
Author(s):  
Faik Agiwahyuanto ◽  
Sudiro Sudiro ◽  
Inge Hartini
Keyword(s):  
Qualitative Study ◽  
Social Security ◽  
Medical Treatment ◽  
Emergency Room ◽  
Medical Record ◽  
Clinical Pathway ◽  
Public Hospital ◽  
Medical Service ◽  
Hospital Director ◽  
Social Security Agency

Percentage of clinical and insurance diagnosis differences at Semarang City Public Hospital tended to increase. If this condition remained, it would lead to upcoding (fraud). The aim of this study was to explain a process of clinical and insurance diagnosis at a hospital in the implementation of Healthcare and Social Security Agency (Health BPJS). This was a qualitative study. Main informants consisted of doctors at an emergency room, surgeons, and internists. Informants for triangulation purpose consisted of a Hospital Director, a hospital verifier, and a head of Medical Record Unit. Data were analysed using content analysis.The results of this research showed that there were any differences in clinical and insurance diagnosis at Semarang City Public Hospital. The cause of these differences was due to differences in diagnosis and medical treatment between medical service standard of doctors at the hospital and a standard of INA-CBGs. To prevent the differences of clinical and insurance diagnosis, the Semarang City Public Hospital had formed an internal verifier team of the hospital and a Clinical Micro System team. A medical committee had a role to minimise the occurrence of upcoding by multiplying kinds of Clinical Pathway as a reference for doctors in diagnosing and determining kinds of treatments for patients.The differences of clinical and insurance diagnosis must be equated to prevent the occurrence of upcoding and disadvantage of the hospital. Efforts to prevent these differences are by adding officers, training coding, making and multiplying algorithm of clinical pathway, forming a team of Clinical Micro System, and monitoring and evaluating medical services.

scholarly journals Gambaran Pasien yang Menggunakan Suplemen Kalsium di Poliklinik Sub Spesialis Bedah Onkologi RSUD Ulin Banjarmasin

2021 ◽  
Vol 8 (1) ◽  
pp. 7
Author(s):  
Adella Adella ◽  
Noor Cahaya ◽  
Siti Rahmah
Keyword(s):  
Medical Record ◽  
Hormonal Therapy ◽  
Public Hospital ◽  
Ace Inhibitor ◽  
Research Result ◽  
Data Retrieval ◽  
Megestrol Acetate ◽  
Calcium Supplements ◽  
H2 Blocker ◽  
Goserelin Acetate

Suplemen kalsium banyak digunakan oleh pasien yang menderita kanker dengan terapi hormonal di poliklinik sub spesialis bedah onkologi RSUD Ulin Banjarmasin. Penelitian ini bertujuan mendeskripsikan karakteristik berupa umur dan jenis kelamin pasien yang menerima suplemen kalsium, jenis kanker, obat lain yang diberikan bersama pemberian kalsium, jenis suplemen kalsium, frekuensi pemberian kalsium, lama pemberian kalsium dan penggunaan suplemen kalsium dari lama pemberian kalsium dan obat terapi hormonal yang digunakan di poliklinik sub spesialis bedah onkologi RSUD Ulin Banjarmasin. eksperimental deskriptif  adalah jenis penelitiannya serta pengambilan datanya dengan retrospektif menggunakan sumber cacatan medik pada tahun 2018. Data Populasi digunakan dengan kriteria inklusi adalah pasien kanker usia >18 tahun, menerima suplemen kalsium dan kriteria eksklusi yaitu penderita kanker dengan informasi catatan medik yang kurang lengkap/tak ditemukan. Total jumlah populasi yang digunakan adalah 55 pasien. Hasil dan kesimpulan penelitian didapatkan karakteristik berdasarkan usia pada rentang 26-35 tahun (1,81%), 36-45 tahun (10,91%), 46-65 tahun (43,64%), 56-65 tahun (40,00%) dan >65 tahun (3,64%); jenis kelamin perempuan (100%); jenis kanker berupa kanker payudara (98,18%) dan kanker tiroid (1,82%); obat lain yang diberikan bersama pemberian kalsium adalah obat golongan hormonal, kemoterapi sitotoksik, analgesik, H2 Blocker, ACE Inhibitor, Antihistamin, Bifosfonat, Analog vitamin D serta multivitamin lainnya; jenis suplemen kalsium yang didapat yaitu kalsium karbonat (100%); frekuensi pemberian kalsium 1x sehari 500 mg (100%); lama pemberian kalsium selama 7 hari (1,82%), 15 hari (1,82%), 20 hari (1,82%), 21 hari (1,82%), 30 hari (92,72%) dan penggunaan suplemen kalsium dari lama pemberian kalsium dan obat terapi hormonal yang digunakan adalah 7, 15, 20 dan 21 hari dengan jumlah pasien masing-masing 1 pasien terapi hormonal yang digunakan yaitu letrozole dan 30 hari dengan jumlah pasien 51 terapi hormonal yang digunakan yaitu letrozole, anasrozole, tamoxifen, goserelin acetate, megestrol acetate, dan levothyroxine. Kata Kunci: Suplemen, Kalsium, Onkologi, Hormonal, Kanker Calcium supplements are widely used by patients who suffer cancer with hormonal therapy at oncology surgery sub specialist polyclinic at Ulin Regional Public Hospital Banjarmasin. The research aims to describe the characteristics of the age and gender of patiens who receive calcium supplements, types of cancer, other drugs given with calcium, types of calcium supplements, frequency of calcium administration, duration of calcium administration and the use of calcium supplements from the duration of calcium administration and hormonal therapy drugs used at oncology surgery sub specialist polyclinic at Ulin Regional Public Hospital Banjarmasin. The research type is non-experimental descriptive and the data retrieval is taken restropective by using medical record as the source in 2018. The population data used with inclusion criteria are patients who suffer cancer with the age of > 18 years old, consumed calcium supplements and the exclusion criteria are patients with incomplete / not found medical record. The total population used are 55 patients. The research result and conclusion shows that the characteristics based on age is between 26-35 years old (1,81%), 36-45 years old (10,91%), 46-65 years old (43,64%), 56-65 years old (40,00%) and > 65 years old (3,64%); female (100%); types of cancer in the form of breast cancer (98,18%) and thyroid cancer (1,82%); other drugs given with calcium are hormonal medicine groups, cytotoxic chemotherapy, analgesic, H2 Blocker, ACE Inhibitor, Antihistamine, Bisphosphonates, Vitamin analogues D and other multivitamins; types of calcium supplements obtained is calcium carbonate (100%); frequency of calcium administration is 1 x 500 mg (100%) each day and duration of calcium administration is 7 days (1,82%), 15 days (1,82%), 20 days (1,82%), 21 days (1,82%), 30 days (92,72%) and the use of calcium supplements from the duration of calcium administration and hormonal therapy drugs used were 7,15,20 and 21 days with 1 patient each of hormonal therapy used letrozole and 30 days with 51 patients using hormonal therapy letrozole, anasrozole, tamoxifen, goserelin acetate, megestrol acetate, dan levothyroxine.

scholarly journals Avaliação da qualidade dos registros de enfermagem em um hospital do Norte do Brasil.

2021 ◽  
Vol 11 (4) ◽  
Author(s):  
Natalia Bianchini Dodo ◽  
Josimeire Cantanhêde De Deus ◽  
Priscilla Perez da Silva Pereira ◽  
José Juliano Cedaro
Keyword(s):  
Health Care ◽  
Qualitative Study ◽  
Medical Record ◽  
Quality Of Health Care ◽  
Medical Records ◽  
Public Hospital ◽  
Northern Region ◽  
Nursing Team ◽  
Quality Of Nursing

Objetivo: avaliar a qualidade dos registros de enfermagem realizados em prontuário de pacientes internados num hospital público municipal da região norte brasileira. Método: estudo quanti-qualitativo, tipo documental, em prontuários de pacientes que permaneceram internados no mínimo 48 horas. O instrumento de coleta avaliava a qualidade dos registros, conforme definição pelo Conselho Federal de Enfermagem. Foram realizadas análises descritivas por meio do Stata®13.0. Resultados: do total de 248 prontuários, 25,9% foram considerados completos, 67,1% incompletos, 6,7% incorretos e 0,3% não estavam preenchidos. Em mais de 90% dos registros estudados se verificou que não havia uma escrita sequencial e concisa, emprego de terminologias técnicas e descrição dos cuidados prestados. Conclusões: Os registros de enfermagem foram considerados com qualidade insatisfatória. Como possíveis caminhos a serem experimentados tem-se o uso de formulários específicos para a Sistematização da Assistência de Enfermagem, implementação do prontuário eletrônico e padronização de siglas.Descritores: Registros de Enfermagem; Equipe de Enfermagem; Qualidade da Assistência à Saúde. EVALUATION OF THE QUALITY OF NURSING RECORDS IN THE HOSPITAL IN NORTHEN BRAZILObjective: to evaluate the quality of nursing records carried out in patients' records in a municipal public hospital in the northern region of Brazil. Method: quantitative-qualitative study, documentary type in medical records of patients who remained hospitalized at least 48 hours. The collection instrument evaluated the quality of the records, as defined by the Federal Nursing Council. Descriptive analyzes were carried out using Stata®13.0. Results: Of the total of 248 medical records, 25.9% were considered complete, 67.1% were incomplete, 6.7% were incorrect and 0.3% were not filled. In more than 90% of the studied registers it was verified that there was no sequential and concise writing, use of technical terminologies and description of the care provided. Conclusions: Nursing records were considered of unsatisfactory quality. As possible ways to be tried it is suggested the use of specific forms for the Systematization of the Nursing Assistance, implantation of the electronic medical record and standardization of acronyms.Descriptors: Nursing Records; Nursing Team; Quality of Health Care. EVALUACIÓN DE LA CALIDAD DE LOS REGISTROS DE ENFERMERÍA EN UN HOSPITAL EN EL NORTE DE BRASILObjetivo: evaluar la calidad de los registros de enfermería realizados en los registros de pacientes en un hospital público municipal en la región norte de Brasil. Método: estudio cuantitativo-cualitativo, tipo documental en registros médicos de pacientes que permanecieron hospitalizados al menos 48 horas. El instrumento de recolección evaluó la calidad de los registros, según lo define el Consejo Federal de Enfermería. Los análisis descriptivos se llevaron a cabo utilizando Stata®13.0. Resultados: Del total de 248 registros médicos, 25.9% se consideraron completos, 67.1% estaban incompletos, 6.7% eran incorrectos y 0.3% no se llenaron. En más del 90% de los registros estudiados se verificó que no había una escritura secuencial y concisa, el uso de terminologías técnicas y la descripción de la atención prestada. Conclusiones: los registros de enfermería fueron considerados de calidad insatisfactoria. Como posibles formas de ser juzgado, se sugiere el uso de formularios específicos para la Sistematización de la Asistencia de Enfermería, la implantación del registro médico electrónico y la estandarización de acrónimos.Descriptores: Registros de Enfermería; Registros; Grupo de Enfermería; Calidad de la Atención de Salud.

scholarly journals Overview Of Ergonomic Aspects In The Storage Room Sub Section Medical Record Waled General Hospital Cirebon District

2019 ◽  
Vol 6 (2) ◽  
pp. 50-53
Author(s):  
Widya Nurbaeti ◽  
Jaenudin ◽  
Iin Indra Nuraeni
Keyword(s):  
Data Analysis ◽  
Medical Record ◽  
Public Hospital ◽  
Room Temperature ◽  
Univariate Analysis ◽  
Risk Of Falling ◽  
Cognitive Ergonomics ◽  
Storage Room ◽  
Physical Ergonomics ◽  
Iron Material

In the storage section of the medical recordat the Waled public hospital. there are problems with ergonomics. high shelves cause medical record files difficult to reach and footing aids used in the form of a former wooden table drawer where the risk of falling to the officer at work, and the unavailability of room temperature indicators to measure ideal temperature and humidity as well as lack of lighting and less space stuffy. The purpose of this study was to review aspects of ergonomics in the medical record storage room. The Used of type research is descriptive. The used method  is observation. The purpose of this study is to overview ergonomic aspects in the medical record storage room. The procedure for collecting data in this study is by observation and measurement. The used instrument is observation and measurement sheets. The population and samples in this study are medical record storage room and the officers. The used data analysis is univariate analysis. The research was conducted on 16 may 2019 at Waled public hospital of Cirebon district.From the results of the study about ergonomic aspects according to The International Ergonomic Association IEA, 2002 devided ergonomics into 4 categories. Physical ergonomics with percentage value of 80% and environmental ergonomics also with a percentage value of 80% do not meet ergonomics standard. Cognitive ergonomics with percentage value of 100% which has the same value with ergonomic Organization with percentage value of 100% meet ergonomics standard. it is suggested that hospital, especially in the filling room should replace foot pedestal devices, should use iron material ladders to advoid and reduce the risk of falling for officer. Should  Install a temperature indicator or hygrometer in medical record storage room. Should Install curtains on glass windows, should clean the floor use a wet cloth to reduce dust and repair damage facilities and infrastructure in filling room.

scholarly journals Management of medical record in installation of inpatient regional public hospital Batara Guru Belopa

2019 ◽  
Vol 6 (7) ◽  
pp. 2773
Author(s):  
Musriati . ◽  
Indar . ◽  
Muhammad Tahir Abdullah
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Public Hospital ◽  
Sampling Method ◽  
Management Information ◽  
Hospital Policy ◽  
Number Of Patients ◽  
Document Review ◽  
Depth Interviews

Background: This research is motivated by the high number of incompleteness of filling in the patient's medical record file in the inpatient installation, which is 30-35% in Regional Public Hospital Batara Guru Belopa.Methods: The research method is qualitative using the phenomenology approach. Determination of informants using purposive sampling method and obtained as many as eighteen informants. Data collection in the form of in-depth interviews, document review and observation. The validity of the data is done by triangulation and credibility test.Results: Management of medical records completeness seen from human resources who still need additional staffin the central part of the hospitalization by looking at the large number of patients and workload of the officers, doctors rarely fill in the full medical record sheets due to negligence of doctors due to other activities or in a hurry. Management of medical records completeness viewed from the procedure, there are still officers in the inpatient department who do not know the flow of exit and entry of the medical record file to the inpatient installation. The management of medical record completeness is seen from the information, implementation of hospital policy regarding the completeness of filling in medical record is not maximal because medical record file is slowly completed and returned to the medical record section.Conclusions: The hospital should be conducted a routine evaluation related to the completeness of the medical record and activated the hospital management information system (HMIS).

scholarly journals Law Enforcement Opens Medical Records through Public Relations Media of Langsa Hospital

SOEPRA ◽  
2020 ◽  
Vol 6 (2) ◽  
pp. 10
Author(s):  
Radhali Radhali ◽  
Tariadi Tariadi ◽  
H.S Brahmana ◽  
Eko Hadiyanto Hadiyanto
Keyword(s):  
Law Enforcement ◽  
Public Relations ◽  
Medical Record ◽  
Medical Records ◽  
Public Hospital ◽  
Regional Hospital ◽  
Online Media ◽  
The Public ◽  
Law Enforcement Officials ◽  
Made In

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

scholarly journals Diffusion of Electronic Medical Record Based Public Hospital Information Systems

2015 ◽  
Vol 21 (3) ◽  
pp. 175 ◽  
Author(s):  
Kyoung Won Cho ◽  
Seong Min Kim ◽  
Chang-Ho An ◽  
Young Moon Chae
Keyword(s):  
Information Systems ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Public Hospital ◽  
Hospital Information Systems

The Completeness and Accuracy of Hepatoma Coding for Medical Procedure Based on ICD-9 CM at Public Hospital in Padang

2022 ◽  
Vol 2 (1) ◽  
pp. 22-25
Author(s):  
Sayati Mandia
Keyword(s):  
Medical Record ◽  
Public Hospital ◽  
Discharge Summary ◽  
Medical Procedure ◽  
Inaccurate Information ◽  
Procedure Code ◽  
History Of ◽  
Quantitative Descriptive ◽  
Item Data ◽  
Code Procedure

Background: Hepatoma  or  hepatocellular  carcinoma  (KHS)  is  a  primary  malignant  tumor  of  the  liver originating from hepatocytes and the 3rd cause of death from cancer in the world. The history of a hepatoma patient can be seen based on the patient's medical record. The filling of medical record is done by doctors, nurses and medical record personel. However, in medical record  filling, incompleteness  is often found and cause inaccurate information. Accuracy coding important for financial of hospital.Methods: Type  of  research  is  quantitative  descriptive,  which  is  to  determine  the  completeness  and accuracy of  the  medical  records  for  hepatoma  cases and procedure code using criteria  for  document  quantitative  analysis in a public hospital, Padang. The study  design  used  a  retrospective  analytical  approach. The variables in the study were completeness of discharge summary and accuracy of hepatoma procedure based on ICD-9 CM. The population in this study were inpatient medical record documents for Hepatoma cases at a public hospital, Padang from June to August 2019, which were 45 medical record documents (discharge summary form) of hepatoma inpatients.Results: From 45 hepatoma patient medical record documents, filling of item name, medical record number, date of admission, indication of the patient being treated, history, physical examination, diagnostic examination, procedures, medications given, medicines used at home, PPBS doctor's signature, DPJP doctor's hand is complete 100% . Highest incompleteness of filling was found  at code ICD (47%) and address item (43%). From 45 discharge summary , accuracy procedure code at hepatome case shows 100 % accurate in ultrasonoggrafi abdomen and ultrasonografi thorax. While that EKG 98% accurate and 95 % rontgen thorax.Conclusions: In general, item data of discahrege summary for hepatoma medical record are completenes; highest incompleteness of filling was found  at code ICD (47%) and address item (43%); Accuracy of code procedure more than 90% in each code procedure.

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