scholarly journals Evaluasi Ketepatan Antibiotik pada Pasien Sepsis

2021 ◽  
Vol 18 (2) ◽  
pp. 194-207
Author(s):  
Ambar Yunita Nugraheni ◽  
Mahyastuty Shintya Putri ◽  
Adi Yusron Saputro
Keyword(s):  
Medical Record ◽  
Observational Data ◽  
Inclusion Criteria ◽  
Medical Record Data ◽  
Exclusion Criteria ◽  
Central Java ◽  
Intravenous Antibiotics ◽  
Record Data ◽  
The Right ◽  
Complete Medical Record

The administration of early intravenous antibiotics was one of the fundamental procedures in sepsis. Inappropriate of antibiotics in septic patients has an impact on mortality and prolongs treatment. The purpose of this study was to evaluate the appropriateness of antibiotics therapy in hospitalized sepsis patients in Central Java based on the parameters right indication, right patient, right drug, and the right dose. This study was observational. Data collected retrospectively and analyzed descriptively. Sampling was done by purposive sampling. The inclusion criteria were inpatients diagnosed with sepsis who received antibiotics therapy with complete medical record data. The exclusion criteria were patients who died of sepsis. Antibiotics analyzed using the DIH 25th edition 2016, IONI 2014, Tata Laksana Sepsis Pada Anak IDAI 2016, Neofax 2014, Kepmenkes PNPK Tata Laksana Sepsis 2017, PPK RS, and SHC Antimicrobial Dosing 2017. Based on data from 108 patients who fulfilled the inclusion criteria obtained results right indication 100%, right patient 97.22%, right drug 90.74%, and the right dose 48.15%. The most used antibiotic was a combination of ampicillin and gentamicin (41.67%), while the single antibiotic was ceftriaxone (12.96%).

scholarly journals Are medical record front page data suitable for risk adjustment in hospital performance measurement? Development and validation of a risk model of in-hospital mortality after acute myocardial infarction

BMJ Open ◽  
2021 ◽  
Vol 11 (4) ◽  
pp. e045053
Author(s):  
Chaoqun Wu ◽  
Danwei Zhang ◽  
Xueke Bai ◽  
Tiannan Zhou ◽  
Yongfei Wang ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Hospital Mortality ◽  
Medical Record ◽  
Risk Adjustment ◽  
Validation Cohort ◽  
Hospital Performance ◽  
Front Page ◽  
Medical Record Data ◽  
Record Data ◽  
Complete Medical Record

ObjectivesTo develop a model of in-hospital mortality using medical record front page (MRFP) data and assess its validity in case-mix standardisation by comparison with a model developed using the complete medical record data.DesignA nationally representative retrospective study.SettingRepresentative hospitals in China, covering 161 hospitals in modelling cohort and 156 hospitals in validation cohort.ParticipantsRepresentative patients admitted for acute myocardial infarction. 8370 patients in modelling cohort and 9704 patients in validation cohort.Primary outcome measuresIn-hospital mortality, which was defined explicitly as death that occurred during hospitalisation, and the hospital-level risk standardised mortality rate (RSMR).ResultsA total of 14 variables were included in the model predicting in-hospital mortality based on MRFP data, with the area under receiver operating characteristic curve of 0.78 among modelling cohort and 0.79 among validation cohort. The median of absolute difference between the hospital RSMR predicted by hierarchical generalised linear models established based on MRFP data and complete medical record data, which was built as ‘reference model’, was 0.08% (10th and 90th percentiles: −1.8% and 1.6%). In the regression model comparing the RSMR between two models, the slope and intercept of the regression equation is 0.90 and 0.007 in modelling cohort, while 0.85 and 0.010 in validation cohort, which indicated that the evaluation capability from two models were very similar.ConclusionsThe models based on MRFP data showed good discrimination and calibration capability, as well as similar risk prediction effect in comparison with the model based on complete medical record data, which proved that MRFP data could be suitable for risk adjustment in hospital performance measurement.

scholarly journals EVALUASI PENGGUNAAN OBAT ASAM URAT DAN POLA PERESEPANNYA PADA PASIEN GOUT ARTRITIS DI INSTALASI RAWAT INAP DI RSUD DELI SERDANG LUBUK PAKAM TAHUN 2020

2021 ◽  
Vol 3 (2) ◽  
pp. 113-117
Author(s):  
Asvia Rahayu ◽  
Romauli Anna Teresia Marbun ◽  
Dian Nopita Sari Manalu ◽  
Sa’adah Siregar ◽  
Vincentia Ade Rizky ◽  
...  
Keyword(s):  
Uric Acid ◽  
Medical Record ◽  
Gouty Arthritis ◽  
Study Data ◽  
The Body ◽  
Prescribing Patterns ◽  
Medical Record Data ◽  
Joint Tissue ◽  
Record Data ◽  
The Right

Uric acid is a disease that arises due to excess purine in the body caused by uric crystals in the joint tissue that attacks the fingers, elbows, knees, toes, toes and heels. Gouty arthritis is a progressive disease caused by deposition of monosodium urate crystals (MSU) found in the joints, kidneys, and other connective tissue due to chronic hyperuricemia. The incidence of gouty arthritis is common in men as many as 25 patients (65.8%) and women as many as 13 patients (34.2%). The incidence of gouty arthritis continues to increase with age, at the age of 21-35 years (7.9%), ages 36-55 years (36.7%), age 56-65 years (28.9%), and at the age of 66 -75 years (26.3%). The purpose of this study was to examine the use of uric acid and its prescription patterns in arthritis patients in Deli Serdang Lubuk Pakam Hospital in 2020 in terms of the right parameters according to the indications, the right patients, the right drugs, and the right dosages. This research is a non-experimental study, data retrospective retrieval was done by looking at the medical record data of arthritis gout patients and analyzed descriptively. Sampling as many as 38 patients with puposive sampling method. Inclusion criteria in this study were patients who were diagnosed with gout and given arthritis medication with complete medical record data. The results of the study evaluated the use of gout and its prescribing patterns in 38 patients at Deli Serdang Lubuk Pakam Regional Hospital in 2020, which were 100% correct, 100% right, 100% right, and 96% right.

Influential Factors in The Law Enforcement Process of Sexual Violence Cases in Children in The City of Semarang

SOEPRA ◽  
2020 ◽  
Vol 6 (2) ◽  
pp. 4
Author(s):  
Liya Suwarni
Keyword(s):  
Law Enforcement ◽  
Sexual Violence ◽  
Medical Record ◽  
Child Protection ◽  
Influential Factors ◽  
Medical Record Data ◽  
Violence Against Children ◽  
Record Data ◽  
The Law ◽  
The City

Background. Cases of sexual violence increase every year, victims ranging from adolescents, children to toddlers. Based on data from the Indonesian Child Protection Commission, abuse and violence against children in Indonesia in 2013 were 23 cases, in 2014 there were 53 cases, in 2015 there were 133 cases, 2017 reached 1,337 cases, and as of July 2018 there were 424 cases. Purpose. Knowing the factors that influence the law enforcement process of sexy violence cases in Semarang City. Method This study uses descriptive analytical methods for cases of violence against children, based on medical record data in hospitals, documents in Mapolrestabes, the District Attorney's Office and the Semarang City Court for the period of January 2015 to December 2018. Results. Based on research results obtained 213 experimental cases section from medical record data in hospitals in the city of Semarang. Most cases of child abuse occurred in 2018 with 72 cases. Most victims are 12-14 years old age group, female. Most types of cases are cases of intercourse. The majority of violations are persons known as victims, perpetrators not working, and most of the places of occurrence are in the defendant's house. At the time of prosecution and trial, the number of cases was significantly reduced to only 8 cases. Factors related to this include lack of evidence, difficulty in obtaining information from victims, convoluted statements of coverage, lack of election, and obtaining diversion rates. Conclusion Cases of sexual violence have increased from year to year. The process of law enforcement on this problem still has many difficulties in each manufacturing process which is still difficult to overcome.

scholarly journals Performance analysis of AES-Blowfish hybrid algorithm for security of patient medical record data

2018 ◽  
Vol 1007 ◽  
pp. 012018 ◽  
Author(s):  
Amir Mahmud H ◽  
Bayu Angga W ◽  
Tommy ◽  
Andi Marwan E ◽  
Rosyidah Siregar
Keyword(s):  
Performance Analysis ◽  
Medical Record ◽  
Hybrid Algorithm ◽  
Medical Record Data ◽  
Patient Medical Record ◽  
Record Data

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

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