Hiding Medical Records Behind the Law

1981 ◽  
Vol 2 (2) ◽  
pp. 5-5
Author(s):  
Jane L. Greenlaw
Keyword(s):  
Nursing Home ◽  
Medical Record ◽  
Nursing Care ◽  
Medical Records ◽  
Self Care ◽  
Healthy Woman ◽  
Financial Responsibility ◽  
Medical Status ◽  
Nursing Home Patients ◽  
Physical Care

The nursing home nurses were faced with a troubling problem. An 87 year old woman, who had been a resident of the home for several years, had gradually become disoriented, confused, and nearly unable to communicate. Nursing care for this otherwise healthy woman continued as always — monitoring and maintaining her medical status with a necessary increase in physical care as her own self-care ability diminished. The problem was the woman's son: he was demanding to see his mother's chart because he believed that she had cancer and that this was being concealed from him. What should the nurses do?The issue is complex and can best be examined in stages. The first question is: does the son have a legal right to see his mother's records? The answer is that in no state does a patient's son or other relative have an automatic legal right, by virtue of his relationship to the patient, to see an adult patient's medical record. Often, particularly with nursing home patients, a relative signs an agreement to assume financial responsibility for expenses incurred by a patient.

scholarly journals Implementation of Documentation of Nursing Care in Wates Hospital

2019 ◽  
Vol 6 (2) ◽  
pp. 68
Author(s):  
Erna Kurniawandari ◽  
Fatma Siti Fatimah
Keyword(s):  
Data Analysis ◽  
Data Collection ◽  
Medical Record ◽  
Frequency Distribution ◽  
Nursing Care ◽  
Medical Records ◽  
Care Process ◽  
Nursing Process ◽  
Nursing Documentation ◽  
Operational Procedure

<p><em>The documentation of nursing care is the important part nurse duty, the best documentation of nursing care process that sees best and have a certain quality should be acurate, complete, and standard. Curently documenting of nursing care in Wates Hospital is practically not yet done according to Standard Operational Procedure. This study aims to know the description of the nursing care of documentation in Inpatient Room of Wates Hospital. This research is descriptive quantitatif which take the sample from inpatient documentation of nursing care in March 2017. The population was about 1106 documents of medical records which the sample obout 111 documents. The technique to take the sample was using cluster random. The research was held on June 2017. The data collection used medical record of patient. The univariat of data analysis used frequency distribution. This research showd that the completeness os documenting of nursing care in assessment aspect (77,5%), diagnosis (93,7%), planning (73,9%), action (45,9%), evaluation (76,6%), nursing care note (45%). The completeness of documentation of nursing care in Inpatient Room of Wates Hospital Kulon Progo is claimed complete (27,9%).</em></p><p> </p><strong>Keywords:</strong> Nursing documentation, nursing process

scholarly journals Demographics and Clinical Characteristics of Adult Patients Hospitalized due to COVID-19 in a Rural/Suburban Integrated Health System in Southcentral Pennsylvania, March through May 2020

2021 ◽  
Author(s):  
Michael A Bohrn ◽  
Ronald Benenson ◽  
Chelsea M Bush ◽  
Theodore Bell ◽  
Cassandra Black ◽  
...  
Keyword(s):  
Nursing Home ◽  
Health System ◽  
Medical Records ◽  
Clinical Characteristics ◽  
Adult Patients ◽  
Integrated Healthcare ◽  
Gastrointestinal Manifestations ◽  
Nursing Home Patients ◽  
Community Population ◽  
Hispanic Patients

Abstract Existing characterizations of COVID-19 admissions have occurred primarily in urban settings. This report describes demographic and clinical characteristics of the first COVID-19 patients presenting to a six-hospital integrated healthcare system in rural/suburban southcentral Pennsylvania. Medical records of adult patients admitted with COVID-19 between March and May of 2020 were retrospectively reviewed for demographics, symptomatology, imaging, and lab values. Results were largely consistent with previous studies, although gastrointestinal manifestations were more prevalent, with diarrhea reported in 25.4% of patients hospitalized due to COVID-19. Nursing home patients represented 10.1% of admissions but accounted for 35.5% of total deaths in our sample. Patients self-identifying as Hispanic were disproportionately affected. Although Hispanic ethnicity was self-reported in only 9% of the community population, Hispanic patients accounted for 34% of admissions. Our data provides a unique focused review of hospitalized COVID-19 patients in a rural/suburban setting.

scholarly journals Motivasi internal perawat terhadap pelaksanaan dokumentasi edukasi terintegrasi di ruang rawat inap

2020 ◽  
Vol 14 (4) ◽  
pp. 529-535
Author(s):  
Dewi Kusumaningsih ◽  
Agustina Sianturi
Keyword(s):  
Medical Record ◽  
Quantitative Study ◽  
Educational Intervention ◽  
Nursing Care ◽  
Medical Records ◽  
P Value ◽  
Nursing Documentation ◽  
Cross Sectional ◽  
Internal Motivation ◽  
Health Educational Intervention

The health educational intervention and inpatient documentation execution  and an internal motivation among nursesBackground: Documentation of the health educational to inpatient is a nursing that evidence record the service of nursing care given to the patients that is useful for patients, nurses, health staffs and hospital. Most of the hospital in Bandar Lampung in the pre-survey, there were of 30% medical records was incomplete filled such as time and date when giving nursing care and signed by nurses, and mostly regarding in health educational documentations.Purpose: To identify the nursing documentation perfection (health education to the inpatient) and an internal motivation among nurses to executionMethod: A quantitative study with cross-sectional approach. The population and the sample were all inpatient nurses at Immanuel Hospital of Bandar Lampung in 2019 of 75 respondent and 75 medical records. The instrument as a questionnaire to explore nurses' internal motivation. Medical record to observe nursing note.Results: Finding of 52.0% respondent has made an incomplete nursing documentation and 46.7% respondents exhibited a poor in internal motivation. The p value was 0.004; and OR 4.643.Conclusion: There was a correlation between nurses' internal motivation and the completeness of health educational documentation. The nurse supervisor should regularly do evaluation the completeness of health educational documentation and hospital management to encourage nurses's internal motivation.Keywords: The health educational; Intervention; Inpatient documentation; Execution; An internal motivation; NursesPendahuluan: Dokumentasi edukasi keperawatan merupakan bukti tertulis perawat atas pelayanan asuhan keperawatan yang diberikan kepada pasien yang berguna untuk kepentingan pasien, perawat, tim kesehatan lain dan rumah sakit. Saat pre survey didapatkan 30% dokumentasi edukasi pasien tidak terisi waktu dan tanggal pelaksanaan, 10% dokumentasi edukasi dalam pasien tidak terisi bagaimana kebutuhan edukasi, selain itu sebanyak 10%  pasien pindahan dalam lembar edukasi tidak terisi tujuan pemberi edukasi di dalam form tersebut.Tujuan: Diketahui hubungan motivasi internal perawat terhadap kelengkapan dokumentasi edukasi di ruang bangsal dewasa Rumah Sakit Imanuel Bandar Lampung tahun 2019.Metode: Jenis penelitian kuantitatif, desain penelitian analitik pendekatan cross sectional. Populasi dan sampelnya  seluruh perawat pelaksana di ruang bangsal  Rumah Sakit Imanuel Bandar Lampung, sejumlah 75 responden dan 75 catatan keperawatan dalam medical record. Instrumen berupa angket untuk mengetahui motivasi internal perawatHasil: Diketahui dari 75 responden sebanyak (52,0% responden melakukan pendokumentasian tidak lengkap. Diketahui dari 75 responden sebanyak 46,7% responden yang mempunyai motivasi internal kategori rendah. Didapatkan hasil p-value=0,004; OR 4,643.Simpulan: Ada hubungan motivasi perawat terhadap kelengkapan dokumentasi edukasi di ruang bangsal dewasa Rumah Sakit Imanuel Bandar Lampung tahun 2019. Saran diharapkan kepala ruangan dapat mengevaluasi secara rutin tentang kelengkapan pengisian dokumentasi edukasi

The effect of Orem's self-care model on nursing care in a nursing home setting

1990 ◽  
Vol 15 (6) ◽  
pp. 659-666 ◽  
Author(s):  
J Faucett ◽  
V Ellis ◽  
P Underwood ◽  
A Naqvi ◽  
D Wilson
Keyword(s):  
Nursing Home ◽  
Nursing Care ◽  
Self Care ◽  
Care Model ◽  
Home Setting ◽  
Nursing Home Setting

scholarly journals Relationship of Nurse's Knowledge Concerning Medical Recording With Nursing Care Document Completeness

2021 ◽  
Vol 1 (1) ◽  
Author(s):  
Dewi Mardiawati ◽  
Linda Handayuni ◽  
Ririn Afrima Yenni ◽  
Fitria Septi Aryani
Keyword(s):  
Medical Record ◽  
Direct Observation ◽  
Nursing Care ◽  
Medical Records ◽  
Outpatient Services ◽  
Relationship Of ◽  
Complete Medical Record ◽  
Lack Of Knowledge

Background: Completeness of medical records is a medical record that is completely filled out by a doctor within ≤ 24 hours of completion of outpatient services or after an inpatient is decided to go home.Methods: This type of research is descriptive. The data were collected using a questionnaire and direct observation. The data were processed by editing, coding, processing, and cleaning, which were analyzed using computerization.Results: The results showed that less than half (46.7%) of the medical record files were incomplete and 33.3% had low knowledge of nurses.Conclusions: The conclusion in this study was that less than half (46.7%) of nurses did not complete medical record files and it was found that nurses lack of knowledge in filling out nursing care documents completely. It is better if reward should be done for nursing care documents.

Perencanaan Arsitektur Sistem Informasi Rekam Medis dan Monitoring Gizi Buruk Berbasis Cloud Computing (Studi Kasus: Dinas Kesehatan Propinsi Jawa Barat)

2017 ◽  
Vol 8 (3) ◽  
Author(s):  
Ova Nurisma Putra
Keyword(s):  
Cloud Computing ◽  
Information System ◽  
Medical Record ◽  
Medical Records ◽  
Monitoring And Evaluation ◽  
Open Group ◽  
Development Method ◽  
Information System Architecture ◽  
Architecture Framework ◽  
Architecture Development

Abstract. West Java Provincial Health Office still faces difficulties in managing information, especially in medical records. Recording and reporting of malnutrition are still done in some stages starting from collecting data from village midwives, puskesmas, Regency/City Health Office then Provincial Health Office and forwarded to the the central office. It is necessary to manage information through service system by utilizing Cloud Computing based on information technology. This research uses The Open Group Architecture Framework (TOGAF) approach in Architecture Development Method (ADM), from Architecture Capability Iteration to  Architecture Development Iteration. Monitoring and Evaluation (M & E) are two integrated activities in the context of controlling a program. The results of this research are planning a medical record information system architecture and monitoring malnutrition based on Cloud Computing with the name of M2Rec (Medical Record and Monitoring) in the form of integrated recommendation and development between current information system and proposed information system architecture.Keywords: togaf adm, medical record and monitoring, cloud computing Abstrak. Perencanaan Arsitektur Sistem Informasi Rekam Medis dan Monitoring Gizi Buruk Berbasis Cloud Computing. Dinas Kesehatan Propinsi Jawa Barat masih mengalami kesulitan dalam pengelolaan informasi yang baik, terutama pada proses rekam medis, pencatatan dan pelaporan gizi buruk masih dilakukan secara bertingkat mulai pengumpulan data dari bidan desa, puskesmas, Dinas Kesehatan Kabupaten/Kota kemudian Dinas Kesehatan Propinsi dan diteruskan ke pusat. Sehingga perlu diupayakan pengelolaan informasi melalui sistem pelayanan dengan memanfaatkan teknologi informasi berbasis Cloud Computing. Penelitian ini menggunakan pendekatan framework The Open Group Architecture Framework (TOGAF) Architecture Development Method (ADM), yaitu iterasi ke satu pada Architecture Capability Iteration daniterasi ke dua pada Architecture Development Iteration. Monitoring dan Evaluasi (M&E) merupakan dua kegiatan terpadu dalam rangka pengendalian suatu program. Hasil dari penelitian ini adalah perencanaan arsitektur sistem informasi rekam medis dan monitoring gizi buruk berbasis Cloud Computing dengan nama M2Rec (Medical Record and Monitoring) yang berupa rekomendasi integrasi dan pengembangan antara sistem informasi berjalan saat ini dengan arsitektur sistem informasi yang diusulkan.Kata kunci: togaf adm, medical record and monitoring, cloud computing.

Analisis Unsur Manajemen dalam Pengolahan Rekam Medis di Rumah Sakit TNI AU Lanud Roesmin Nurjadin

2018 ◽  
Vol 1 (1) ◽  
pp. 20-25
Author(s):  
Henny Maria Ulfa
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Processing Method ◽  
Qualitative Approach ◽  
Check List ◽  
Training Material ◽  
Patient Medical Record ◽  
Qualitative Descriptive ◽  
Material Element ◽  
Descriptive Method

Hospitals must conduct a medical record activities according to Permenkes NO.269 / MENKES / PER / III / 2008 about Medical Record, to achieve the purpose of medical record processing required 5 management elements are: man, money, material, machine, and method. The medical record processing that has been implemented at the Hospital TNI AU LANUD Roesmin Nurjadin that is coding, coding only done for BPJS patients whose conducted by the officer with education background of D3 nursing, it be impacted to the storage part is wrong save and cannot found patient medical record file because are not returned. The purpose of this research is to know the element of management in the processing of medical records at the Hospital TNI AU LANUD Roesmin Nurjadin. This research is done by Qualitative descriptive method, Qualitative approach, instrument of data collection of interview guidance, observation guidance, check list register, and stationery, number of informant 6 people with inductive way data analysis. The result of this research found that Mans elements only amounts to 2 people so that officers work concurrently and have never attended training, material element and machines elements of medical record processing not yet use SIMRS and tracer, while processing method elements follow existing habits and follow the policy of hospital that is POP organization. Keywords: Management elements, medical record processing

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