scholarly journals Patient Clinical Data Integration in Integrated Electronic Medical Record System for Health Care Facilities in Indonesia

2017 ◽  
Vol 13 (2) ◽  
Author(s):  
Arif Kurniadi ◽  
Retno Pratiwi
Keyword(s):  
Health Care ◽  
Data Integration ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Clinical Data ◽  
Data Exchange ◽  
Clinical History ◽  
Health Care Facilities ◽  
Portal System ◽  
Care Facilities

Complete patient service requires continuous support of clinical history. This can be realized by integrating electronic medical record data. The limitation is the wide variety of software, formats, and data dictionaries used in healthcare facilities. This was a descriptive analysis study with cross sectional approach to find open source electronic medical record integration model for clinical data exchange between health care facilities. Respondents were doctors, nurses, pharmacists, laboratory staffs, and person in charge of hospital information system as informant for content analysis. From the study, we managed a web-based service portal to implement clinical data integration that can be accessed by clinician registered within the Ministry of Health. The patients clinical history is stored in the hospital database and requires unique OpenIDRM code on the Health Service Server to integrate it. OpenIDRM contains all of the patients medical record number, as one patient may have several different medical record numbers in several hospitals. In conclusion, clinician can access the patients clinical history by opening a web portal system through a unique OpenIDRM code.

AUDIT SYSTEM INFORMATION ELECTRONIC MEDICAL RECORD AS STUDENT ONLINE LEARNING

JURTEKSI ◽  
2021 ◽  
Vol 8 (1) ◽  
pp. 49-58
Author(s):  
Wahyu Wijaya Widiyanto ◽  
Sri Wulandari
Keyword(s):  
Health Care ◽  
Information System ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Quality Measurement ◽  
Field Work ◽  
Health Care Facilities ◽  
Care Facilities ◽  
Iso 9126 ◽  
Almost All

Abstract: In the current digital era, almost all health care sectors require fast, precise, detailed, and valid services. The results of observations show that during lectures, students still have difficulty understanding the flow of input, process, and output of a good application, and do not know and have an idea about Application Software in Health Care Facilities that are already running in health facilities because some students do Field Work Practices. placed in health care facilities institutions still use manual systems with paper and recording in ledgers, during the current pandemic. In this study, an electronic medical record information system was designed and built as a student learning application regarding health service applications, system accuracy test using ISO 9126, where ISO 9126 looks at Functionability, Reliability, usability, efficiency, maintainability, and portability of a good system and provides recommendations if there are findings that the system does not meet the needs. The results of this study obtained the value of the Information System that was built only 75,92593 % which is the result of quality measurement so that this application does not fall into the category of the ISO 9126 standard because there are Portability Characteristics, namely Adaptability and Installability elements are not met, for these finding recommendations for improvements are given so that the system can run perfectly. according to the need for use.            Keywords: Covid-19, Electronic Medical Records, Learning Media, ISO 9126 Abstrak: Pada era digital sekarang, hampir semua sektor pelayanan kesehatan membutuhkan pelayanan yang cepat, tepat, detail, dan valid. Hasil observasi menunjukkan bahwa selama perkuliahan mahasiswa masih kesulitan memahami alur input, proses, dan output dari suatu aplikasi yang baik, serta belum mengetahui dan mempunyai gambaran tentang Software Aplikasi di Fasilitas Pelayanan Kesehatan yang sudah berjalan di fasilitas kesehatan dikarenakan beberapa mahasiswa yang melakukan Praktek Kerja Lapangan ditempatkan di institusi fasilitas pelayanan kesehatan masih menggunakan sistem manual dengan kertas dan pencatatan di buku. Pada penelitian ini dirancang dan dibangun sebuah sistem informasi rekam medis elektronik sebagai aplikasi pembelajaran mahasiswa mengenai aplikasi pelayanan kesehatan, uji akurasi sistem menggunakan ISO 9126, dimana ISO 9126 menilik Functionability, Reliability, usability, efesiency, maintainability dan portability sistem yang baik serta memberi rekomendasi apabila ada temuan sistem yang belum sesuai kebutuhan. Hasil dari penelitian ini diperoleh nilai Sistem Informasi yang dibangun hanya 75,92593 % yang merupakan hasil pengukuran kualitas sehingga aplikasi ini tidak masuk kategori standar ISO 9126 karena ada Karakteristik Portability yaitu unsur Adaptability, dan Installability tidak terpenuhi, untuk temuan ini diberikan rekomendasi perbaikan agar sistem dapat berjalan sempurna sesuai kebutuhan penggunaannya. Kata kunci: Covid-19, Media Pembelajaran, Rekam Medis Elektronik, ISO 9126

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

scholarly journals TINJAUAN PELAKSANAAN NILAI GUNA REKAM MEDIS BAGI PASIEN DI RUMAH SAKIT UMUM IMELDA PEKERJA INDONESIA (RSU IPI) MEDAN TAHUN 2018

2020 ◽  
Vol 5 (1) ◽  
pp. 80-84
Author(s):  
Johanna Christy ◽  
Afni Efani Putri S
Keyword(s):  
Health Care ◽  
Medical Care ◽  
General Hospital ◽  
Medical Record ◽  
Medical Records ◽  
Health Care Facilities ◽  
Use Value ◽  
Care Facilities ◽  
Conducting Research

ABSTRAK Rekam medis adalah berkas yang berisi catatan dan dokumen tentang identitas pasien, pemeriksaan, pengobatan, tindakan dan pelayanan lain kepada pasien pada sarana pelayanan kesehatan. Tujuan penelitian ini adalah untuk mengetahui bagaimana pelaksanan nilai guna rekam medis bagi pasien. Jenis penelitian ini adalah deskriptif bertujuan menggambarkan secara sistematis fakta dan karakteristik objek dan subjek secara tepat. Waktu penelitian ini dilakukan pada bulan Juli di Rumah Sakit Umum Pekerja Indonesia Medan (RSU IPI) Tahun 2018. Populasi dalam penelitian adalah 440 berkas rekam medis. Dalam melakukan penelitian, peneliti mengambil sampel sebanyak 81 berkas rekam medis. Berdasarkan hasil penelitian yang dilakukan di RSU IPI pelaksanaan nilai guna rekam medis sudah terlaksana dengan baik, dilihat dari tersedianya ringkasan masuk dan keluar, resume, lembar operasi, identifikasi bayi, lembar persetujuan tindakan, lembar kematian pada setiapberkas pasien pulang meninggal, asuhan keperawatan didalam berkas rekam medis. Tetapi dalam pengisian berkas rekam medis petugas rekam medis belum mengimplementasikan nilai guna rekam medis dengan baik. Kesimpulannya pelaksanaan nilai guna rekam medis sudah baik namun dalam pengisian berkas rekam medis lebih di perhatikan sesuai Permenkes 269 Tahun 2008 Tentang rekam Medis sehingga pelaksaaan nilai guna rekam medis dan pengisisan berkas rekam medis berjalan lebih baik.   Kata Kunci: Rekam Medis, Nilai Guna Rekam Medis, Berkas Rekam Medis                                             ABSTRACT   Medical record is a document that contains records and documents about patient identity, examination, treatment, care and other services for patients in health care facilities. The purpose of this study was to study how the implementation of the use of medical records for patients. This type of research is descriptive which addresses the systematic problem and the appropriate characteristics of objects and subjects. When this study was conducted in July at the Medan Indonesian Workers General Hospital (RSU IPI) in 2018. The population in this study was 440 medical record documents. In conducting research, researchers took 81 samples of medical records. Based on the results of research conducted at the IPI General Hospital, the implementation of the use value of medical records has been carried out well, seen from the availability of incoming and outgoing assessments, proceeding, surgery sheets, accessing infants, action approval sheets, consent sheets on each patient's return documents, medical care care. However, in applying medical records, medical record officers have not applied the use value of medical records properly. Conclusion the reclamation of the value of the medical record has been better in the reclamation of the medical record is better with the approval in accordance with Minister of Health Regulation 269 of 2008 About the Medical Record requires the implementation of the value of the medical record and the filling of the medical record better.

scholarly journals Implementing electronic medical record in family practice in Slovenia and other former Yugoslav Republics: Barriers and requirements

2009 ◽  
Vol 137 (11-12) ◽  
pp. 664-669 ◽  
Author(s):  
Marko Kolsek
Keyword(s):  
Health Care ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Health Care Professionals ◽  
Medical Records ◽  
Data Exchange ◽  
Data Retrieval ◽  
Primary Health ◽  
User Friendly ◽  
Better Than

The author describes problems related to the implementation of electronic medical record in family medicine in Slovenia since 1992 when first personal computers have been delivered to family physicians' practices. The situation of health care informatization and implementation of electronic medical record in primary health care in new countries, other former Yugoslav republics, is described. There are rather big differences among countries and even among some regions of one country, but in the last year the situation improved, especially in Montenegro, Serbia and Slovenia. The main problem that is still unsolved is software offered by several companies which do not offer many functions, are non-standardized or user friendly enough and is not adapted to doctors' needs. Some important questions on medical records are discussed, e.g. what is in fact a medical record, what is its purpose, who uses it, which record is a good one, what should contain and confidentiality issue. The author describes what makes electronic medical record better than paper-based one (above all it is of better quality, efficiency and care-safe, easier in data retrieval and does it offer the possibility of data exchange with other health care professionals) and what are the barriers to its wider implementation.

ETHNOVETERINARY MEDICINAL USES OF SOME MEDICINAL PLANTS ON PNEUMONIA BY THE GUJJAR AND PAHARI TRIBES OF POONCH DISTRICT OF JAMMU AND KASHMIR

2017 ◽  
Vol 23 (2) ◽  
Author(s):  
JAMIL AHMED KHAN ◽  
RAJINDER PAUL
Keyword(s):  
Health Care ◽  
Medicinal Plants ◽  
Medicinal Plant ◽  
Natural Resources ◽  
Indigenous People ◽  
Health Care Facilities ◽  
Jammu And Kashmir ◽  
Medicinal Uses ◽  
Modern Health Care ◽  
Care Facilities

Poonch district of Jammu and Kashmir is a reservoir of enormous natural resources including the wealth of medicinal plants. The present paper deals with 12 medicinal plant species belonging to 8 genera of angiosperms used on pneumonia in cattle such as cows, sheep, goats and buffaloes in different areas of Poonch district. Due to poverty and nonavailability of modern health care facilities, the indigenous people of the area partially or fully depend on surrounding medicinal plants to cure the different ailments of their cattles. Further research on modern scientific line is necessary to improve their efficacy, safety and validation of the traditional knowledge.

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