The Medical Record: Narration and Story as a Path Through Patient Data

1996 ◽  
Vol 35 (02) ◽  
pp. 88-92 ◽  
Author(s):  
E.-H. W. Kluge
Keyword(s):  
Expert Systems ◽  
Conceptual Framework ◽  
Medical Record ◽  
Patient Data ◽  
Analog Model ◽  
Patient Profile

AbstractKay and Purves' proposed narratological model of the medical record is based on the familiar phenomenological insight that the perception of data is conditioned by the conceptual framework of the perceiver. Unfortunately, unless handled very carefully, this approach will make the significance of a medical record unique to the person who constructed it and impermeable to outside scrutiny. However, when integrated into the analog-model of the medical record, the narratological model can be accommodated as the clinician-relative construction of a patient profile within the data that make up the medical record. Some implications for the construction of expert systems and competence analysis are indicated.

Knowledge-Based Decision Support for Diagnosis and Therapy: On the Multiple Usability of Patient Data

1989 ◽  
Vol 28 (02) ◽  
pp. 69-77 ◽  
Author(s):  
R. Haux
Keyword(s):  
Expert Systems ◽  
Statistical Data ◽  
Patient Data ◽  
Attribute Selection ◽  
Patient Specific ◽  
Statistical Data Analysis ◽  
Inference Mechanism ◽  
Diagnosis And Therapy ◽  
Knowledge Based ◽  
Clinical Registries

Abstract:Expert systems in medicine are frequently restricted to assisting the physician to derive a patient-specific diagnosis and therapy proposal. In many cases, however, there is a clinical need to use these patient data for other purposes as well. The intention of this paper is to show how and to what extent patient data in expert systems can additionally be used to create clinical registries and for statistical data analysis. At first, the pitfalls of goal-oriented mechanisms for the multiple usability of data are shown by means of an example. Then a data acquisition and inference mechanism is proposed, which includes a procedure for controlling selection bias, the so-called knowledge-based attribute selection. The functional view and the architectural view of expert systems suitable for the multiple usability of patient data is outlined in general and then by means of an application example. Finally, the ideas presented are discussed and compared with related approaches.

scholarly journals PENGELOLAAN DATA REKAM MEDIS MELALUI SISTEM PENOMORAN DAN PENYIMPANAN UNTUK MENINGKATKAN MUTU PELAYANAN KESEHATAN DI KLINIK GIGI DAN UMUM PURI MEDICAL

2019 ◽  
Vol 3 (2) ◽  
pp. 135
Author(s):  
Rahmi Septia Sari
Keyword(s):  
Health Care ◽  
Medical Record ◽  
Community Service ◽  
Storage System ◽  
Patient Data ◽  
Health Care Facilities ◽  
Medical Record Data ◽  
Care Facilities ◽  
Record Data ◽  
And Storage

Pemeliharaan dan pengambilan data rekam medis merupakan fungsi penting dalam pelayanan disetiap fasilitas asuhan kesehatan. Peningkatan tuntutan akan informasi kesehatan ini mengharuskan fasilitas untuk memelihara sistem informasi yang efektif dan efisien. Mengenai sistem penomoran, penyimpanan dan retensi dari manajemen rekam medis di Indonesia banyak jenisnya. Bentuk sistem penomoran dan penyimpanan yang baik merupakan tahap awal dalam pemberian pelayanan terhadap pasien. Pengambilan dan penyimpanan rekam medis yang tepat merupakan elemen penting dalam pemberian pelayanan. Perlu kehati-hatian dalam merencanakan sistem penomoran dan penyimpanan. Tujuan utama dalam melakukan pemberian penomoran adalah mengidentifikasi data pasien. Penulis berpendapat bahwa dengan menggunakan bentuk pemberian nomor metode apapun rahasia pasien dapat terjaga. Pemberian nomor ini dilakukan pada saat pasien mendaftar atau kontak dengan sarana pelayanan kesehatan. Hal tujuan utama dalam melakukan pemberian penomoran adalah mengidentifikasi data pasien. Pemberian nomor dilakukan pada saat pasien mendaftar atau kontak dengan sarana pelayanan kesehatan. Dalam kegiatan ini kami berusaha untuk mengoptimalkan sistem pelayanan kesehatan  di Klinik Puri Medical melalui penyuluhan tentang sistem penomoran dan penyimpanan data Rekam Medis  yang baik dan memudahkan petugas dalam pengambilan dan penyimpanan data Rekam Medis tersebut. Pelaksanaan Pengabdian kepada masyarakat ini kami menguraikan tentang pengelolaan data Rekam medis melalui tatacara sistem penomoran dan penyimpanan data Rekam Medis. Metode yang dilakukan dengan cara memberikan materi dan dipresentasikan serta didiskusikan dengan staf yang hadir dalam Pengabdian tersebut dengan beberapa tahap, antara lain dengan pemaparan materi tentang sistem penomoran dan penyimpanan yang disampaikan kepada staf/petugas bagian Rekam medik yang hadir dalam acara Pengabdian Kepada Masyarakat, setelah itu dilanjutkan dengan praktik lapangan, jika ada hal yang kurang dipahami dalam pelaksanaan maka akan dilanjutkan dengan tahap bimbingan dan konsultasi antara staf rekam medis dengan tim Pengabdian Kepada Masyarakat,tahap akhir dalam jangka beberapa minggu akan dilakukan monitoring dan evaluasi apakah ilmu yang di berikan telah teraplikasi dengan baik di klinik tersebut. Kata kunci: Rekam Medis, Penomoran, Pengarsipan, Klinik ABSTRACT Corresponding author: * [email protected]   Maintenance and retrieval of medical record data is an important function of service in every health care facility. This increasing demand for health information requires facilities to maintain effective and efficient information systems. Regarding the numbering, storage and retention systems of medical record management in Indonesia, there are many types. The form of a good numbering and storage system is the initial stage in providing services to patients. Proper collection and storage of medical records is an important element in the delivery of services. Care needs to be taken in planning the numbering and storage system. The main purpose in numbering is to identify patient data. The author believes that by using any method of giving numbers the patient's secret can be kept. Giving this number is done when the patient registers or contacts with health care facilities. The main goal in making numbering is to identify patient data. The number is given when the patient registers or contacts with health care facilities. In this activity we are trying to optimize the health service system at Puri Medical Clinic through counseling about the numbering system and storing good Medical Record data and facilitate the officers in retrieving and storing the Medical Record data. This Community Service Implementation describes the management of medical record data through the procedure for numbering and storing medical record data. The method is done by providing material and presented and discussed with the staff present at the Service with several stages, including the presentation of material about the numbering and storage system that was delivered to the staff / officers of the Medical Record section who attended the Community Service event, after it is continued with field practice, if there are things that are not understood in the implementation it will be continued with the guidance and consultation phase between the medical record staff and the Community Service Team, the final stage within a period of several weeks will be carried out monitoring and evaluation whether the knowledge provided has been applied well in the clinic. Keywords: Medical Record, Numbering, Archiving, Clinic

The Ontario oncology electronic medical record (EMR): The integration of end user and provincial needs.

2013 ◽  
Vol 31 (31_suppl) ◽  
pp. 248-248
Author(s):  
Vishal Kukreti ◽  
Sara Lankshear ◽  
Arthur G. Manzon ◽  
Nancy Wolf ◽  
Shafiq Habib ◽  
...  
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Quality Indicators ◽  
Online Survey ◽  
Clinical Care ◽  
Functional Requirements ◽  
End User ◽  
Oncology Patient ◽  
Full Spectrum ◽  
Patient Profile

248 Background: The use of ambulatory electronic medical record (EMR) systems within oncology provides an opportunity for aligning provincial, local and end-user patient-centred quality indicators in the design, delivery and evaluation of clinical care and resource utilization. The aim of this provincial initiative is to define the “meaningful use” for the Oncology EMR by identifying the essential data elements and functional requirements required to facilitate integrated care, information standards (both local and provincial), and system integration needs. This paper presents the results of a provincial field study designed to determine end-user needs for information and quality metrics. Methods: Data collection included two separate onsite focus groups at each of the 13 regional cancer programs, with a focus on Clinical and Operational requirements. A total of 141 participants, representing physicians, interprofessional clinical team members, administrators and health information specialists were involved. An additional online survey was used for optimal engagement, with a total of 194 respondents, primarily nurses and physicians. Inclusion and exclusion criteria were developed to assist in coding and distillation of concepts generated. Results: A total of 1,598 ideas were generated (Clinical = 997, Operational = 601). Multiple rounds of content analysis were used to eliminate duplicates, identify common themes and distill the wealth of information down to the “vital few” discrete information requirements that should be included in the oncology EMR. At this time, 63 clinical and 55 operational concepts have been identified to support clinical care as well as operational planning and system evaluation. The online survey has helped define the data required for a Provincial Oncology Patient Profile within the EMR. Conclusions: The study employed significant consultation to merge end user and existing provincial quality measurement needs in order to define the Ontario Oncology EMR. A full spectrum of quality indicators identified through these processes will inform the future provincial priorities for information standards and quality monitoring that will be facilitated by a standardized EMR.

scholarly journals PERANCANGAN SISTEM INFORMASI REKAM MEDIS PASIEN RAWAT JALAN BERBASIS WEB DI KLINIK SEHAT MARGASARI BANDUNG

2017 ◽  
Vol 3 (3) ◽  
Author(s):  
Johni S Pasaribu ◽  
Johnson Sihombing
Keyword(s):  
Information System ◽  
Patient Care ◽  
Medical Record ◽  
Medical Records ◽  
Fundamental Problem ◽  
Patient Data ◽  
Health Clinic ◽  
Web Based ◽  
Expected Outcome ◽  
Care Information

[Id]Sistem infomasi rekam medis pasien rawat jalan adalah sistem informasi yang bertujuan mengelola data pasien yang berobat hingga pasien tersebut keluar dari rumah sakit atau klinik pada periode tertentu. Sistem informasi yang dirancang sangatlah penting untuk mencegah terjadinya kesalahan prosedur dalam pelaksanaan pendaftaran dan pengelolaan data. Sistem informasi dalam klinik kesehatan ini adalah sistem informasi yang berisikan data pasien, data obat, data transaksi dan rekam medis pasien. Adapun sebelumnya kinerja sistem dalam pelayanan pasien yang berjalan pada klinik kesehatan secara umum belum optimal karena masih pada pengolahan data pasien dan data rekam medis masih menggunakan media pembukuan atau manual. Pengelolaan data pasien di Klinik Sehat Margasari masih belum efektif karena sistem yang digunakan kurang lengkap sehingga pelayanan pasien menjadi lambat dan rekam pasien sering hilang atau tidak ditemukan. Maka pelayanan pasien menjadi tidak efektif dan efisien, karena sistem manual pembukuan memperlambat pembuatan laporan atau pencarian data pasien. Sistem informasi pelayanan pasien dirancang bertujuan untuk membangun sistem informasi yang terkomputerisasi, sehingga memudahkan pihak klinik kesehatan mengolah data pasien, obat, transaksi, rekam medis, tindakan medis pasien hingga pencetakan laporan.Hasil yang diharapkan dari penelitian ini yaitu terbangunnya sistem informasi rekam medis berbasis web untuk memudahkan Klinik Sehat Margasari dalam membantu pengolahan data pasien, obat, transaksi, rekam medis, tindakan medis pasien hingga pencetakan laporan. Rumusan masalah dari penelitian ini adalah bagaimana membangun sistem informasi rekam medis di Klinik Sehat Margasari sehingga dapat menyajikan informasi yang akurat serta efisien. Adapun tujuan dari penelitian ini adalah menghasilkan suatu sistem informasi rekam medis pasien rawat jalan.Kata kunci : Sistem Informasi, Rekam Medis, Pasien Rawat Jalan[En]Medical record outpatient information system is a system that aims to manage the data of patients who register for treatment until the patient is discharged from the hospital or health center in a given period. The information system is important because it is designed to prevent errors in the execution of the procedure of registration and data management so that it can be done as well as possible. This information systems in health clinic is an information system that has patient data, drug data, transaction data and medical records of the patient. As before for the performance of the system in patient care in health clinic in generally not optimal because it is still in the processing of patient data and medical records are still using books or manuals. Management of patient data at the Health Clinic Margasari Bandung is still not effective because the system used is less complete so that the patient's service to be slow and patient records are often missing or was not found. Therefore care patients at health clinic become ineffective and inefficient, because manual system making slow reporting or searching data patient. Patient care information system designed aiming to establish a computerized information system, making it easier for the health clinic process patient data, drugs, transaction, medical records, medical actions to patient until print out of reports. The expected outcome of this research is to build information system web-based to facilitate Health Clinic Margasari Bandung making it easier for the health clinic process patient data, drugs, transaction, medical records, medical actions to patient until print out of reports. Fundamental problem of this research is how to install information system for medical record patient information system at Health Clinic Margasari that make information representation accurately and efficiently. The aim of this research is to produce a information system of medical record outpatient.

scholarly journals Aplikasi Filling Rekam Medis Menggunakan Metode Algoritma Turbo Boyer Moore

2020 ◽  
Vol 5 (2) ◽  
pp. 259
Author(s):  
Beni Harzani ◽  
Diana Diana
Keyword(s):  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
Community Health Centers ◽  
Processing System ◽  
Patient Data ◽  
Search Problem ◽  
Test Results ◽  
Medical Record Data ◽  
Record Data

Nagaswidak Health Center is one of the community health centers that is quite large and has complete facilities. But the problem that is often faced by officers in the puskesmas is the medical record data processing system which is still manual, causing the accumulation of patient medical record file data, in addition to patients who have been checked before and lost their medical records, it is very difficult for officers to find back, so the officer made a new medical record data. To overcome this problem, a Medical Records Filling Application was made at the Nagaswidak Health Center which includes the processing of medical records, patient data, drug data, action data, doctor data, and admin logins. So that the data search problem is not difficult, the turbo boyer moore algorithm method is applied which is expected to later be able to facilitate the search for patient data in the medical record filling application. Based on the test results Boyer Moore's Algorithm successfully applied to search for the beginning of a word, middle word, and final word. And the level of ease and usefulness of medical records application using Boyer Moore's algorithm obtained results that the level of ease is 80% and 100% usability rate.

scholarly journals PERANCANGAN SISTEM INFORMASI REKAM MEDIS BERBASIS WEB (STUDI KASUS DI KLINIK BERSALIN SRIATI KOTA SUNGAI PENUH – JAMBI)

2016 ◽  
Vol 2 (2) ◽  
Author(s):  
Tiara Handayani ◽  
Gerson Feoh
Keyword(s):  
Information System ◽  
Life Cycle ◽  
Medical Record ◽  
Medical Records ◽  
Systems Development ◽  
Patient Data ◽  
Web Based ◽  
Development Life Cycle ◽  
Icd 10 ◽  
Maternity Clinic

<p>ABSTRACT<br />The records officer at Maternity Clinic Sriati Sungai Penuh - Jambi in its management and reporting of patient data are still using manual systems. It has caused a delay in the delivery of information and report on daily data patients. Thus, it needs a system of web-based medical record information that can assist officers in the medical record of the patient data management processing. This system design method uses development life cycle (Systems Development Life Cycle-SDLC) which consists of planning, analysis, design, implementation, and use. Meanwhile, the purpose and benefits of the design of this information system is to produce a system of web-based medical record information in Maternity Clinic Sriati River Sungai Penuh - Jambi. With this information system, it eases medical records clerk in the management of patient data whichh includes patient registration process, the recording of patient medical records, physician data recording, data recording space, the search code ICD 9 CM and ICD code search 10. In addition, this information system produces a variety of reports and patient medical record information that is required for management decision making.<br />Keywords: Information Systems, Medical Record, Maternity Clinic, Web.<br />ABSTRAK<br />Petugas rekam medis di Klinik Bersalin Sriati Kota Sungai Penuh - Jambi dalam pengelolaan dan pembuatan laporan data pasien masih menggunakan sistem manual. Hal ini menyebabkan terjadinya keterlambatan dalam penyampaian informasi dan pelaporan data harian pasien. Maka diperlukan sebuah sistem informasi rekam medis berbasis web yang dapat membantu petugas rekam medis dalam proses pengelolaan data pasien tersebut. Metode perancangan sistem ini menggunakan siklus hidup pengembangan sistem (Systems Development Life Cycle-SDLC) yang terdiri dari tahap perencanaan, analisis, desain, implementasi, dan penggunaan. Sedangkan tujuan dan manfaat dari perancangan sistem informasi ini yaitu menghasilkan sebuah sistem informasi rekam medis berbasis web di Klinik Bersalin Sriati Kota Sungai Penuh - Jambi. Dengan adanya sistem informasi ini, dapat memudahkan petugas rekam medis dalam pengelolaan data pasien yang meliputi proses pendaftaran pasien, pencatatan rekam medis pasien, pencatatan data dokter, pencatatan data ruang, pencarian kode ICD 9 CM, dan pencarian kode ICD 10. Selain itu sistem informasi ini menghasilkan berbagai laporan-laporan serta informasi rekam medis pasien yang dibutuhkan pihak manajemen untuk pengambilan keputusan.<br />Kata kunci: Sistem Informasi, Klinik Bersalin, ICD 9 CM, ICD 10</p>

scholarly journals Siremis: Sistem Informasi Rekam Medis Puskesmas Kecamatan Matraman Jakarta

2019 ◽  
Vol 3 (2) ◽  
pp. 116 ◽  
Author(s):  
Lydia Salvina Helling ◽  
Endang Wahyudi ◽  
Hasanudin Hasanudin
Keyword(s):  
Information System ◽  
Medical Record ◽  
Medical Records ◽  
Patient Data ◽  
Use Case ◽  
Collection System ◽  
District Health ◽  
Running System ◽  
Activity Diagrams ◽  
Use Case Diagram

  The Matraman Sub-district Health Center, which was established on July 3, 1977 in DKI Jakarta, is one of the puskesmas that always records and searches its patient data in Medical Records. This Puskesmas requires a Medical Record Information System so that the recording of the patient's medical history can be stored and arranged in a good mechanism. The development of the patient data collection system in Medical Records uses the Waterfall method in developing the software. While the process of collecting data by conducting interviews with the relevant parts. Depictions of the running system can be seen in the form of Activity Diagrams and proposed systems can be seen in the Use Case Diagram, ERD and LRS. Research produces a Medical Record Information System that helps related parts in recording and searching for patient data needed quickly and precisely so that medical action can be done immediately.

scholarly journals Design and Implementation of a Web Based Health Information System

2020 ◽  
Vol 5 (3) ◽  
pp. 1-11
Author(s):  
Moses Kwasi Torkudzor ◽  
Patrick Atsu Agbemabiese ◽  
Wellington Amponsah
Keyword(s):  
Information System ◽  
Health Information ◽  
Medical Record ◽  
Health Information System ◽  
Patient Data ◽  
Data Availability ◽  
Quality Data ◽  
Web Based ◽  
Record Keeping ◽  
Design And Implementation

Health Information System aims at improving and enhancing the delivery of quality, data availability and administrative effectiveness of people’s health. Medical record has come under severe threat as a result of the manual system of medical record keeping in spite of its important functions. This system of record-keeping involves taking down patient data on pieces of paper, which are put into files and kept in cabinets. In fact, this is an improper means of documentation resulting in loss and mismatch of patient data, and time wastage. It is alsocumbersome, bulky and consumes a lot of the office space. In this paper, a complete web-based health information system is designed to solve these problems so as to enable users handle details on policies efficiently and effectively. A test of the system over various network topologies reveals that time taken to move a packet and received acknowledgment for standalone, LAN, WAN and Intranet is 3ms, 4ms, 8ms and 10ms respectively. These short periods of time show faster and efficient delivery of health activities. The Web Based HealthInformation System thus provides significant benefit to institutions as it can capture data and store it in the developed database for future use. Citation: Kwasi, T. M., Patrick, A.A, Amponsah Wellington, A. Design and Implementation of a Web-BasedHealth Information System, 2020; 5(3): 1－11. Received: August 4, 2019Accepted: September 30, 2020

scholarly journals RANCANG BANGUN SISTEM INFORMASI REKAM MEDIS BERBASIS WEB

2021 ◽  
Vol 7 (1) ◽  
pp. 1-6
Author(s):  
Hari Santoso ◽  
Sugesti Sugesti ◽  
Notatema Anugrah Gea
Keyword(s):  
Information System ◽  
Medical Record ◽  
Medical Records ◽  
Research Method ◽  
Patient Data ◽  
The Internet ◽  
Conventional System ◽  
Web Based ◽  
Research And Design ◽  
Computerized System

Medical record is a file that contains records about the patient's identity, examination, treatment, actions and other health services to patients. The speed of obtaining data and processing of data is very much needed in the current technological era. With the development of technology makes people think to be able to work more effectively and efficiently. One of them is making a conventional system into a computerized system. By utilizing website facilities that are connected to the internet, medical records can be more effective and efficient in searching and recording medical history. In this research a web-based information system is designed using the PHP programming language and MySQL database using the waterfall method as its research method. With this system, it is expected to be able to overcome the various needs of users to search for patient data and perform data processing as well as facilitate users in making reports. From the results of research and design that has been implemented to produce medical record applications that facilitate the processing of patient data.

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